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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 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. AO <br /> Job Address City Lot Size/Acreage <br /> �l <br /> Owner's Namet-lam _ �f,7.f�YY�� Address 3� ��'���U Phone <br /> Cl <br /> Contractor Address icense No.4 XAM P h o n <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C.1 DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR D OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O industrial ❑ 0 Bottom OO Ma�nt Ca Dia. of Well Excavation Dia. of Well Casing <br /> F] Domestic/Private Gravel Pack I�l�Tracy Type of Casing_ Specifications <br /> Il Public �1-1 Other f 1 Delta Depth of Grout Seal Type of Grout \ <br /> I rrigadon Approx. Depth�I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump iwT H-P. State Work Done <br /> Well Destruction 0 Well Diameter /to Sealing MatArlali Depth <br /> Depth 4W, Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is m <br /> available within 200 feet.M 1 <br /> 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. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Properly Line <br /> �NMEN A HEAL TN <br /> SEEPAGE PITS 11 Depth Size Number {CES <br /> SUMPS Lt Distance to nearest: Well Foundation Property Lin 'V <br /> DISPOSAL PONDS ❑ <br /> I hereby terrify 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 canifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person i such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cartifies the fol; i g; "I Ice 'fy that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of C nla." <br /> The applicant t call o I requi spections. Complete drawing on r ers ids. <br /> Signed Title: Date <br /> DEPARTMENT USE ONLY <br /> Application Accep ed by Date 3/4 Area �� <br /> Pit or Grout Inspection by Date Final Inspection by QV Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Bax 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AM �t REMITTED CKSH RECEIVED BY DATE �3 PERMII,T��'N�O. <br /> EH 13-24 1REV.m t"sr 117:67 <br /> OUNI �-Q�V ,��� I <br /> EH 1 <br /> 4.2E O.' <br />