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SAN JOAQUIN 6Ol.-1y� 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 /> . 4 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 Coupty Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin Countv_j Public Hew)th $PTv_Snb <br /> Lot Size/Acreage <br /> Job Addre ✓ _ � .� <br /> r _ , <br /> n r'•s Name Ad]iress Phone !J <br /> r <br /> TYPE OF WELL/PUMP: NEWWELL ❑ WELLAEPLACEMENT F7 DESTRUCTION Li out of Service Well ❑ <br /> PUMP INS -ALLATIO SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS <br /> - — <br /> INTENDED USE--ri�F.. TYPE OF WELL: -`PROBLEM AREA —CONSTRUCTION SPECIFICATIONS—, <br /> n Industrial _;:�.._❑-Open,Bottoms, ❑_-Manteca�+�Dia.;of Well'Excava_tion f Dia. of Well Casing <br /> C] omestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications. -- I <br /> b[ic Cl Othef.- _ ' --n Delta '"" Depth of Grout Seal Type Grout j <br /> Y 1 <br /> I d b <br /> I Irrigation _Approx.Dept I I Eastern Surface Sed[ Installed ' <br /> Repair Work Done U Type of Pump ¢ H.P, Sta-' oek Do <br /> Well Destruction ❑ Well Diameter r Sealing Material & Depth f <br /> Depthi r , FinerMaterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I'$REPAIRIADDITION t I DESTRUCTION•I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units:---.Number-of-bedrooms 77' AE _ <br /> Character of soil to a•depth-of 3 feet: 1Vate? table depth <br /> SEPTIC TANK �O�Type/Mfg Capacity r*' No.Compartments <br /> PKG. TREATMENT PLT. ❑ [. r ,_ ; "Method of Disposal 11, <br /> Distance to nearest: 'Weiler Foundation 1 = Propefty-Line y `I <br /> e. <br /> LEACHING LINE El—Nov,& Length of lines Total length/size <br /> FILTER BEI] 1-1 Distancerto-nearest: ,;..,.Welt_ Foundation_ - Property Line <br /> SEEPAGE PITS F' ' l f Depth t r Size Number r <br /> SUMPS �� r LI. Distance to nearest: Well Foundation' -- Property Line <br /> DISPOSAL PONDSN ❑ <br /> I hereby certify that 1 have prepared this application and that the woik 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 signature certifies the following: "I certify that in the performance of the work for 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 Californlie.Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this paimit isiasded,Sl st 816employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican i call for al r r ins ctions. Complete drawing on re sid <br /> Sign d Tit Date: v <br /> I` Ft�R DEPARTMENT USE ONLY / 7 e <br /> Application Accepted by Date 4 Area, <br /> Pit or Grout Inspection by Date 1 Final lnspection Date�� <br /> s j i <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquip, County;Publfc-Health Services <br /> Environmental Health Permit/,Services <br /> 445 N Sad Joaquin,-P O Box 2009, Stkn, CA 95201 <br /> E AMOUNT UE AMOUNT REMITTED 5 , RECEIVED BY DATE PERMIT'N CA� <br /> EH 13.24(REV.1 i n e� l / !� Z <br /> EH 11.26 <br /> r <br />