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SAN �IOAQUIN COUIrgYapI' � HEALTH $ERYICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN jOAQUIN; PHONE (209)468-3420 <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> construct and/or install the work herein described. This <br /> Application is hereby <br /> made to San Joaquin County for a permit to c b lations of San I <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and egu <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage F <br /> d <br /> Job Address <br /> Phone <br /> G Address -� - <br /> Owner"s Nam } <br /> n G-4 CJP� License NI.V2a Phon <br /> l tactor aL •L Address N n DES7RLfCTION 0 Out of Service Well <br /> Cont WELL REPLACEMENT NEW WELL d OTHER 0 Monitoring Well a <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR e� <br /> PUMP INSTALLATION O DISPOSAL FLD. PROP. LINE <br />� SEWER LINES �.---�— ,, pITSlSUMPS .� <br /> DISTANCE TO NEAREST: SEPTIC TANK �� AGRICULTURE WELL OTHER WELL <br /> FOUNDAsTION �-- <br /> h <br /> INTENDED USE TYPE OF WELL PR09LLFM AREA CONSTRUCTION SPECIFICATIONS _ Dia. of Welt Casing <br /> 0 Open Bottom Cl Manteca Dia. of Well Excavation <br /> C-] IndustrialCasing- <br /> 1111r, <br /> Specifications <br /> CJ Tracy Type of Casing_ <br /> `{f�lDomestic/Private Cl Gravel Pack Cl Type of Grout r <br /> C} Other Delta Depth of Grout Seal <br /> I'i Public Surface Seal Installed by 110 l} <br /> t I Irritation Approx. De h_�,f[^I�I Eastern State Work Don 1� <br /> 'C4 Type of Pump [ <br /> H.P. <br /> Repair Work Done pealing Materiel & Depth <br /> Well Destruction © Well Diameter <br /> Filler Material fir Depth <br /> Depth Fri <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITIO. I DESTRUCTION I I alvailablerwi within 200 fa trued rl public sewer is <br /> installation will serve: Residence— Commercial other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: - <br /> Capacity�-.�-- No. Compartments <br /> SEPTIC TANK. 0 TypelMfg Method of Disposal <br /> PKG. TREATMENT PLT. C} Foundation -- Property Line <br /> Distance to nearest: Well <br /> - O <br /> Total length/size -� <br /> LEACHING LINE ❑ Na. f4 Length of lines Foundation �---• pfoperty Line 4 <br /> FILTER BED <br /> Distance to nearest: Well - <br /> - <br /> Size Number <br /> SEEPAGE PITS l 1 Depth Property Line <br /> SUMPS <br /> LI Distance to nearest; Well Foundation <br /> f DISPOSAL PONDS C1 <br /> TN <br /> 1 hey 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 /> reb <br /> r rules and regulations of the San Joaquin County following: work for <br /> Home owner or liicenseucn manner as to become subject to workman'srtcompensation laws of California,"Contractor's hir ng or subthis `cont acct ng signature <br /> employ any person n 6 <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman' eompens <br /> tion laws of Ca' <br /> Thea ant must l for all required ctio . Complete drawing an re►else side. <br /> Title: � } Date: <br /> Signed X <br /> A$�DEPARTMENT USE ONLY <br /> Date 2� 2 Area Z <br /> Application Accepted by <br /> j Final Inspection by Date <br /> Pit or Grout Inspection by Date , <br /> Additional Comments: <br /> Applicant - Return all copies to: EnvironmentalJoaquin oHealth UntY upermit/Services <br /> blic Health vices <br /> l 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 13-241REV.I/N 51 <br /> EH 14.26 <br /> I - <br />