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SAN QUIN COUNTY PUBLIC HEALTH < ICES ENVIRONMENTAL HEALTH DIVISIG_ 1601 E. HAZELTON AVE. , PHONE (209)468-3420 PAYMENT P 0 BOR 2009, STOCKTON, CA 95201 RECEIVED PERKIT EXPIRES 1 YEAR FROM DATE ISSUEDS�R 0 3 '01 (Complete in Triplicate) SAN JOAQU!N CO!1N'TV Application is hereby made to San Joaquin County for a permit to construct and/or install the 'r,4bed'.I(+T1ils application is made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the;• Joaquin County Public Health Services. �r� N! �i`f?f� . t' 4 hpt?s` grvisen Job Address �11 S N mpi-i to 1 City _►-`PfN�t ( y Lot Size!Acreage Vr T11-4 (° , 945-&3 Owner's Name �1► t ' "46-0MtAddress 7� ,>. oh Phone �r}eSfU r Contractor iCnyiro►.rn-e.n*1 CynSvlf`rtAddress X00 5h0YPltrE Hvj Sv�te29 �'I� YA4 t �� e q15 License No. Phone � B� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT (1 DESTRUCTION O Out of Service Well ❑ 1►�& PUMP INSTALLATION O SYSTEM REPAIR O OTHER C Monitorinf Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f DISPOSAL FLD --T PROP. 'INE y 15 17C.Pl'• S r' FOUNDATION"-10 AGRICULTURE WELL OTHER WELL _ fr e*1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 4 A t �� I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �� Specifications I PublicII�SOthertordtr— n Delta Depth of Grout Sea Type of Grout i IrrtOatron L Approx. Depth 1 I Eastern Syrf ce Seal Installed by a^� Repair Work Done U Type of Pump H. 'j�V(� �Staje Work O e _ Well Destruction ❑ 7M Diameter 2— Sealing Material i Depth l�ep�1 f .zr,s� rS Corivz` - Depth Filler Material 3 Depth t2p•-v- e.- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if ptlblc sewer is available within 200 feet) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms N r / Character of soil to a depth of 3 feet: IV Water table depth { S Z's SEPTIC TANK O Type/Mfg Capacity /�✓� No. Compartments _ 1V PKG. TREATMENT PLT. O Method of Disposal AIA Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines dotal length/size ation FILTER BED D Distance to nearest: Well Foundjy� Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundati Property Line _ DISPOSAL PONDS ❑ I hereby certify 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applicant must call for ad required inspections. Complete drawing on VI G /, reverse side. / q l' Signed X Title: f/" I;ki t OA+-0-)r61-f 1 Date: —I I -( FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Rarelton Ave., P 0 Box 2009, Stockton, CA 95201 3 h r M1 n 0 -10 FEE AM0v INFO OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE t ERMIT NO. CASH EH 13-21(REV.ria Sl EH 1 4.26