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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 O BOX 2009, STOCKTON, CA 95201 NO W ok . <br /> PERMIT EXPIRES1 YEAR FROM DATE ISSUED N ', j,LR <br /> (Complete in Triplicate) S1 <br /> Application is madebinmCmwliande to ce withuSanCounty <br /> Joaquinfor <br /> Countypermit <br /> Ordinanceconstruct <br /> No. 549and1862-and thethe <br /> Rules andherein <br /> Regulations-of SanThis <br /> apps <br /> Joaquin County Public Health Services. <br /> -Lot Size/Acreage <br /> ob Address 2 r� <br /> .J ] / — <br /> Owner's Name <br /> ' Address �.Pl!Y� y��' — Phone <br /> ontractor <br /> Address License No, Phone <br /> T PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION C1 Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSA FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CO RUCTION SPECIFIC IONS Dia of Well Casing <br /> D Industrial ❑ Open Bottom D Manteca of Well Excavation _ <br /> Type o _ Specifications <br /> FJ Domestic/f Private C1 Gravel Pack D Tracy Type of Grout _ ] <br /> FI Public [-1 Other F1 Delta Depth of Grout Seal <br /> I I Irrigation w Approx. Depth I i Ea in Surface Seal Installed by,— <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REP I ! DESTRUCTION i arvailableseptic <br /> w thin 200 feet.) it public sewer is <br /> i installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartrrients <br /> Method of Disposal <br /> PKG. TREATMENT PLT. C7 <br /> Distance to nearest: Well Foundation Property One <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line 1 <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 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 California." Contractor's hiring or subcontracting signature <br /> cartiTies 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 /> ggn:d <br /> pplicant m forall r ed ' ction plete drawing on re side.Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> i Date 3 3 O Area <br /> Application Accepted by k2n% <br /> Pit or Grout Inspection by <br /> Date Final Inspection by L Data f <br /> Additional Comments: T <br /> San Joaquin County Public.Health Services <br /> Applicant - Return all copies to: <br /> Environmental Health Permit/Services <br /> i' 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 <br /> F <br /> FEF C1C RECEIVED 9Y -DATE PERMiT N0. ��• <br /> 1111 INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> ` r'�'� t of -30 <br /> . EN 14-M IREV.V n 51 S -w <br /> FH t4.7a <br />