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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES P,2iv M <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT F IRES ]. YEAR FROM DATE ISSUED <br /> (Complete in. Triplicate) - 9 $ / " 2, U L7 <br /> Application is hereby made to San 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. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address City 1&&Lot Size/Acreage <br /> Owner's Name Address _ Phone 7 �J <br /> 4 , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP_INSTALLATION ❑ w •: SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> -A FOUNDATION AGRICULTURE WELL OTH LL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT/ ECIFICATIONS ` <br /> L7 Industrial \❑ Open Bottom ❑ Manteca Dia. all Exca tion Dia. of Well Casing ' <br /> 1-1 Domestic/Private Cl Gravel Pack ❑ Tracy pe of Casing Specifications <br /> 1'l Public El Other n Delta`. De th-of Grout eal'�---'���--� --+ <br /> - "'" P Type of Grout <br /> I I Irrigation Approx. Depth. l I E rn, Surface Seal stalled by 3 Q <br /> Repair Work Done U Type of Pump N,H.P.: State Work Done T <br /> i Well Destruction 0 Wel! Diameter Sealing Material & Depth } z-- <br /> Depth /Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IT REPAIRIADDITION i I DESTRUCTION I i INo septic system permitted if public sewer is <br /> ..available within 200 feet.) , <br /> Installation will serve: ResidenceLb--commercia! Cher + t I <br /> Number of living units: Number of bedrooms = i-, <br /> Character of soil to a depth of 3 feet: i Water Bible depth <br /> SEPTIC TANK D Type/Mfg a Capacity No. Compartments <br /> PKG. TREATMENT PLT. C7 t (AJ <br /> "Method of,D+i s 1 <br /> Distance to-nearest.-.—Well- - - - ..foundation Property tihe'—/u <br /> - <br /> LEACHING LINE Cl No. & Length of linesength/siie i <br /> E FILTER BED Culot��I h7 Distance to nearest: Wafl �✓,i� _Fondation Property Lima-- ' <br /> 1 <br /> SEEPAGE PITS 11 Depth Size �mber 5.f <br /> SUMPS LI Distance to n rest: Well F undarion r Property Line 2 + <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San'Joaquin county <br /> Home owner or licensed agent's.iignature certifies the following; t 4' � <br /> "I certify that in the performance of-the work,}or. <br /> which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor'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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant rn1#I call for al quired inspections. Complete drawing on reverse side. <br /> x� -- <br /> Signed X Title: Date: 2 �- <br /> f <br /> DEPARTMENT USE ONLY ) r <br /> Application Accepted by y Data , <br /> res <br /> Pit or Grout Inspection by Date Final Inspection by :Date -7 <br /> / f <br /> Additional Comments: �"•.�+ <br /> Applicant - Return alit copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services f <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH f)ATE PERMIT'NO, t <br /> EH 13.21.IREV.r1.N 3� l . <br /> �_EH 11-20 t57r _ <br />