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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 EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 1 Application is hereby glade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coaopliartce with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r <br /> DJob Address City Lot Size/Acreage <br /> ��'* F � <br /> 1 !n h I_�� r� Phone <br /> Owner's Name -,,,ate ,- - � Address <br /> CLicense No. Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION c Out of ServicW well IZ <br /> Monitoring Well 7 <br /> PUMP INSTALLATION F1 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C) Industrial ❑ Open Bottom ❑ Mameca� Dia. of Well Excavation Dia. of Welt Casing <br /> Type of Casing- <br /> 1'} <br /> Specifications. <br /> fa 9- <br /> DpmesticlPrivate ❑ Gravel Pack ❑ Tracy <br /> I'} Public D Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation —Approx. Depth I l Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> 1 Well Destruction ❑ Weil Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTA LATION I 1 REPAIRIADOITION 1 DESTRUCTION aNailsepticable system <br /> 200}matted if public sewer is <br /> nstallation will serve: Residence? Commercial_ Other <br /> Number of living units: Number of bedrooms 1— _ . <br /> of foil to a depth of 3 feet: .. Wates table depth /05- <br /> 'Character / <br /> SEPTIC TANK Oe- Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PIT. El ''� ,, Meihod of Disposal <br /> Distance to;nearest: Well 100. Foundation 'Property Line <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> FILTER BED 1-1 Distance to nearest: Wall Foundation Property Line <br /> i Number <br /> SEEPAGE PITS 11 Depth Sire <br /> i SUMPS Cl Distance to nearest: Well Foundation Property Line e <br /> DISPOSAL PONDS ❑ <br /> ill be done in accordance with San Joaquin county ordinances, state laws; an <br /> dC- <br /> I hereby certify that I have prepared this application and that the work w <br /> l rules and regulations of the San Joaquin County <br /> 1 Home owner or licensed agent's signature cenifies 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 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 applican ust call r all{equired inWec Ions. Complete drawing n reverse side. <br /> Signed e- Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> r- <br /> Application Accepted by Date _ Area. <br /> j Pit or Grout Inspection by Date Final Inspection b Data 7 <br /> Additional Comments: Old:Z <br /> I Applicant - Return all copies to: San 3 aquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn CA 95201 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH Y ERMIT'NO. <br /> 1 INFO <br /> F Oy ° <br /> . EN 1 .21(REV.r h Sl <br /> Ek 14.26 <br />