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9 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ;'445 N SAN JOAQUIN, PHONE (209)468-3420 , <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'F (Complete in Triplicate) <br /> , <br /> Application is hereby made to Stan Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 51+4 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address J40- City Lot Size/Acreage I � <br /> Owner's Name _;_P�//'YI ` `C72� Address ✓ A Phone <br /> Contractor Address/ )cense No,::M36 23.Phone 823 <br /> TYPE OF WELL/PUMP: -..,..NEW_W.ELLr -WELL REPLACEMENT n D.ES.T.RUCTION.0.Out Lf Servicc,Well ❑ <br /> PUMP INSTALLATION.[. SYSTEM REPAIR_0OTHER Q Monitoring Well <br /> f+ DISTANCE TO NEAREST: SEPTIC TANK J_ SEWER LINES 10. DISPOSAL FLDLW :F PROP. LINE��.L <br /> g FOUNDATION L \AGRICULTURE WELL OTHER WELL �. PIT$/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl I dd rias ❑ Open Bottom anteca Dia. of Well Exc ation Dia. of Well Casin <br /> fl <br /> ravel Pack 0 Tracy Type of Casingevri S Specifications <br /> I'I Public CI Other 11 Delta Depth of Grout Seal Type of Grou <br /> I i Irrigation I6t1._Approx.,Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth �! <br /> Depth l�� Filler Material ti Depth r i <br /> t �J <br /> TYPE OF SEPTIC WORK;, NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> }t ;I available within 200 feet.) <br /> Installation will serve: Residence!I Commercial_ Other Q� <br /> Number of living units: Number of bedrooms <br /> s <br /> Character of soil to a depth of 3 feet:, Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Gl/ : �l Method of Disposal <br /> Distance to nearest: Well Foundation Property Line V <br /> LEACHING LINE 0 No. & Length of lines Tota) length/size <br /> FILTER BED l_1 Distance to nearest: Wall Foundation{ 4 Property Line <br /> SEEPAGE PITS 11 Depth C Size `"` `Number <br /> SUMPS ' Ll Distance to nearest: Well Foundationry Property Line , <br /> DISPOSAL PONDS ❑ i tk r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws,...Q <br /> y rules and regulations of the San Joaquin County L ., ,,,,.�, <br /> 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, It shall not`. <br /> I employ any person in such manner as to become subject to workman's compensation laws of Cal ifornia.•' Cont raclor's hiring or sub-contracting-signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ parsons subiect"to workman's compensa-I <br /> tion laws of California." <br /> The applican m call or all req ed ins tions. Complete drawing on reverses e. r� <br /> o <br /> Signed XJ'! Title: �' Date: <br /> FO gEPARTMfNT USE ONLY <br /> Application Accepted by a iJ i DateC"AArea <br /> Pit r Grou' nspection by Date Final Inspection by Dat}ir/a <br /> Additional Comments: 136 / 13(rC'( <br /> Applicant - Re,�urn all cgpites/to: San Joaquin County Public Head Services <br /> Environmental Health Permit/Services <br /> IM 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 t <br /> FEE AMOUNT DUE', AMOUNT.-REMITTED CK RECEIVED BY -- -DATE PERMIT'NO. <br /> INFO ).CASH <br /> `'` 1. <br /> . EH t3-44 I#IEV.I/n 5) W <br /> EH 114.40 a <br />