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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O -BOX 2009, STOCgTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) C 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. 544 and 1862 and the.,Rules and Regulations of San Joaquin County Public Health Services. Job Address _Z3 aoe City Lot Size/Acreage Owner's Name —, 7� -- Address ry / Phone Contractor s»�GLS --Address r ` /Y� icense No ,1 _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL PI.TSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA "' CONSTRUCTION SPECIFICATION n Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing El Domestic/Private Cl Gravel Pack M Tracy Type of Casing_ Specifications i I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout 11 Irrigation —.Approx. Oepth,.,.-t-l-Eastern.,,^ _ y:5urfaee Seal Installed by_ -- { Repair Work Done L] Type of Pump H.P. State Work Done W Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth ✓' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION TY DESTRUCTION I I lNo septic system permitted if public sewer is .la available within 200-teet.l._ ,-- ,,.,,,,;, ^- Installation will serve: Residence Commercial e Other v l i Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: 4 Water table depth i l SEPTIC TANK ❑ Type/Mfg Capacity _Nb. Compartments G PKG, TREATMENT PLT. ❑ , Method of Disposal , Distance to nearest: Well S Foundation Property Line . LEACHING LINE No. & Length of tines Total length/size X Fr F FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Si Number_ } SUMPS Distance to nearest: Well A222 Foundation L!50,1 ' Property line .�r k DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt 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 parson 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 all r ired ins tions. Complete drawing on reverse side. Signed X Title a' '! ___ Date: 1 . FOR DEPARTMENT USE ONLY x ' Application Accepted by Date Area Pit or Grout Inspection by 1c Date Final Inspection by Date Z r, Additional Comments: p " Applicant - Return all copies to: -San Joaquin County.;Public Health Services -:•Enbiropmental Health Permit/Services ' _ � __ � + :•. `445•N San -Joaquin, 0 Box 2009;=-Stkn,-CA,95201 �FEE-1 AMOUNT DUE t�AMOUNT REMITTED CX RECEIVED BY DATE PERMIT"N0. INFO /j�[ ��p+ p Ift-.29ffol EN 13-24(REV.i H 5J Spq, /! � f� I rJS 8 � f7 �Z 2- EH 14.20 1