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Y <br /> ►D; t`r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> i P O 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 work 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 Services. <br /> Job Address Lot Size/Acreage R9 G:` o_ <br /> Owner's Name � D Address t9 8-7 7 Ne � '�' ,Phone <br /> Contract r Address ` 7L License No. 297-7& Phone �S`SQO� <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ out of Service Well ❑ <br /> k PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 13 Monitoring Well L] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _ FOUNDATION_ AGRIC U L TUBE-WELL -0. _WELL. _P_ITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation - Dia. of Well Casing <br /> [a Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'1 Public to Other (-1 Delta Depth of Grout Seal Type of Grout <br />.. I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth ` <br /> Depth Filler Material Depth \�1( <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1REPAIR ADDITION DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of-living units: _1_ Number <br /> =;Ie� Water <br /> Character of soil to a depth of 3 feet: fable depth <br /> SEPTIC TANK O Type/Mfg, Capacity. - No. Compartments. - <br /> PKG. TREATMENT PLT. ❑ '- - - Method of Disposal <br /> n, Distance to nearest: Well l Foundation;" Property Line <br /> LEACHING LINE No. & Length of lines dotal length/size 0 Y a <br /> FILTER'BED Cl Distance to nearest: Well so 4 Foundation 10 i' Property Line 5 t � <br /> r SEEPAGE PITS l l Depth Size ©�'®nqy rNumber <br /> ' SUMPS Distance to nearest: Well J50 + Foundation �Q � Property Line 5+ <br /> DISPOSAL PONDS © ��_ <br /> �- " lfiaieby testify that'I-have pre-oared-this application and that the work will be done inca cordance with San Joaquincounty ordinances, state.laws, and <br /> rules and regulations of the San Joaquin County F.. <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 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-subject4o•workman'a compensa- <br /> tion laws of California." <br /> The applicant ust call for' eq ad inspections. Complete drawing on reverse side. <br /> t' <br /> Signed X �Title: y` — Date: 04 <br /> k a. <br /> oFOR DEPARTMENT USE ONLY _r , <br /> Application Accepted by Date. / Area <br /> i Pit or Grout Inspection by Date Final Inspection <br /> k ti <br /> i Additional Comments: ` <br /> 4 <br /> _ Applicant - Return all copies to: San Joaquin County ,Public Health Servi <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 'x <br /> �r <br /> a FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY RAIE PERMIT'NO. � <br /> EH13-24(REV.It M 51 /� • / ,8 +- / / <br /> i EH 14.26 r JJJ <br /> R <br />