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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. fill Job Address City Lot Size/Acreage 2�3 VJ Owner's Nam) Ins Address �, Pjhone Conlraclor � Address � License No. Phone _ TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT n DESTRUCTION n Out of Service Well Cl PUMP INSTALLATION D SYSTEM REPAIR D OTHER D Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial O OperyBottom D Magteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ��W�'rf 1 Pack ,�Y',�Z. Type of Casing_ _ __ Specifications I'1 Pu fl Other fI Delta Depth of Grout Seal ____ Type of Grout rngauonApprox. Depths 1 astern Surfs eal Installed by Repair Work Done Type of Pump _A'ldlrl H.P. State Work Don Well Destruction D Well Diameter �,� Sealing Materiel i Depth , ub pu-yo Depth Filler Material i Depth !p / / ♦� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is �J available within 200 feet.) Installation will serve: Residence _ Commercial _ Other In Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water 0006M E NT SEPTIC TANK D Type/Mfg Capacity No. C° � [� Vr PKG. TREATMENT PLT. 0 Method oi_i�[o's81 Ery Distance to nearest: Well Foundation Property LinAU G 2 f)--1992 LEACHING LINE D No. 8 Length of lines Total length/sfihllll IC 1-I1-Al I 1 1 4 rRyi :l `, FILTER BED C-1 Distance to nearest: Well Foundation Pr&0�kV QW�1i:.Pd1 Al fff A[]i J DI'di'1VXJ SEEPAGE PITS 11 Depth Size -_— Number _ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D I hereby sonify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe so in such manner as to beco subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies tVanimst ng. "I ce fy that in the pe rmencs of the work for which t s perm is issued, I shall employ persons subject to workman's compensa tion lawsa." The appliall t II a it c s. Complete drawing on rev rse e. Signed X Title: Date: FOR DEPARTMENT USE ONLY1�y I I Application Accepted by Date �2-- Area /T Pit or Grout Inspection by —__ Date __________-__ Final Inspection by De16Oda /-a7�4L .• k well ce..dz � c .-tsot�d G� Applicant - Return all copies to. San Joaquin County Public ffealt—h Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 NEIQN,FE AMOUNT DUE A/MMOUNT REMITTED CCK RECEIVED BY g. DATE � PERMIT NO . EH 13.21 tv.r i n er / C_ "- T� �!'v T cru �J v �7 7 EM 14-30