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SAN AlrQUIN COUNTY PUBLIC HEALTH S,..0WICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, 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. E� Job Address ©3 t&t:4 m5t,'tekM-r. City —"-- Lot Size/Acreage�� n + 1 KAY 1�S - Owner's Name _Etssts. Qn-At. Address SSC Ilio It Dta%%%SMil Phone 49iq =631 4100 L57- 7 Contractor u viii%t4gj, 11, Address L%7T E 04Ak License No.�lu�, Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 7 DELLSTRUCTIO�•1 O Out of Sery ce Well Ll PUMP INSTALLATION O SYSTEM REPAIR ❑ -1 X OTHFR'� 1+Monitoring Well 3A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ ins' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS lit `rC,7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation p Dia. of Well Casio \x Domestic/Private O Gravel Pack O Tracy Type of Casing_ i W L Specifications I'I Public I.1 Other Delta Depth of Grout Sea] T pe of Grout 7..� I I Irrigation �.Approx. Depth I Eastern Surface Seal Installed ^•; Repair Work Done 0 Type of Pump H.P. State Work Done _ Welt Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms n\ Character of soil to a depth of 3 feet: Water table depth r�.1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments d PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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: "1 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 spot a m at I for required inspgctions. Complete drawing on rover" side. Signed Title; "�'E , '^' 'q"�� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �` V " Area Pit or Grout Inspection by Data? Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ti. 0-110, Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEINFO AM(O7UNTT��DUE AMOUNT fREMITTED SASH '�I,IRE/ICEIVED BY DATE I PERMIT NO. rEH 14.211 V.rix Sr� �( �(`7 1315 �'y1y ( � g.�Y $� EH tx*Zs 1 1 Ir Il , -- tT a