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- h <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 /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the worst herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic� ' <br /> Job Address r2 ` j �'e, cam' " .p � City _ Lot Size/Acreage <br /> Owner's Nam eV ' �J ` ^*-""'� Address nc 75 4 Phone <br /> . r r CO <br /> Confrac r W Address O, License No32S•2"' Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR C OTHER ElMonitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> N AGRICULTURE WELL —�j OTHER WELL PITS/SUMPS j <br /> INTENDED U`SEEXV1R0WL0tMtEAM ULTrqZ571 ft <br /> RUCTION SPECIFICATIONS <br /> W �`n Industriil - _ -Q o/�togm- —El Manteca'' Dia. of Well Excavation�— 01#,of Well Casing j <br /> [-.), 4 <br /> ,Domestic/Private �Lf�istL, Type"of,Casing_ Specification <br /> :-� <br /> I F;paiGlic Cl Other rl Delta Depth of Grout"Seal Type of Grout <br /> I I Irrigation �.Approx. Depth I I Eastern Surface Seal InstBjled by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth - <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW I�ISTAL�ATION I I REPAI ADDITION DESTRUCTION l I (No septic system permitted if public sewer is t <br /> /r/ available Within 200 feet.), <br /> Installation will serve: Residence Commercial_ Other SAN JOAQUIN COUAT1 I'=1PUBLiC HEALTH SERVICES <br /> Number of living units; _1___ Number.of b r oms ENVIIi0I�M1'A1TAL HEALTH DL413ION <br /> f Character of soil to a depth of 3 feet: &7'� a :C?,,a11121�A1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED C) Distance to nearest: Well "Foundation Property Line <br /> SEEPAGE PITS Depth Size ° Number <br /> r - f; <br /> SUMPS Ll Distance to nearest: Well _ Foundation I� Property Line t <br /> DISPOSAL PONDS ❑ , - <br /> `I hereby cenify that I have prepared this"application and that_the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> �r rules and regulations of the San Joaquin County � � ` " <br /> 11 <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 work rnar s laws-of-California.'I Contractor's hiring or sub-contracting signature <br /> F. 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 all for I re uir inspections. Complete drawing on reverse � <br /> id \ �,4 <br /> '� If f^ k <br /> Signed X <br /> v � ;• `_ ` >` s�- .k. 'FOR DEPARTMENT USE ONLY S <br /> Application Accepted by F Date Area <br /> r <br /> r Pit_or_Grout Inspection by Date Final-Inspection by - flare ' <br /> Additional Comments: ` <br /> X4 �"� 1 <br /> Applicant - Return all copies to: Bain Joaquin County PubliczHealth Services�/�jf3[i yfre, <br /> Environmental Health Permit/Services C- <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 Int <br /> FEE AMOUNT DUE AMOUNT REMITTED x RECEIVED BY O TE PERMIT'NO. <br /> ),NFO R� / 9,7 <br /> EH 13-2/(REV.t 1"5) 7a <br /> t <br /> EH 1416 ••�� ! // 7 <br /> t ' <br />