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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 95241 <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 City Lot Size/Acreage <br /> r f ! ,�} <br /> Owner's Name ..V Address �PIo Gv t�k r06 10 '! Phone "4rp ,9 <br /> �a7fp <br /> Contractor .Snr r address V 0 �f &i" d License No. �3�J3� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> D Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FT Domestic/Private ❑ Gravel Pack* M'Tracy Type of Casing_ Specifications <br /> U) Public Ia Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth 11 Eastern Sp ee Sedl Installed by _ <br /> Repair Work Done IT- Type of Pump _r(4. H.P. / State Work pone _re : Aex,00 <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth �`� Filler Materiel & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <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: Walllt� fi <br /> PKG. TREATMENT PLT,SEPTIC TANK ❑ Type/Mfg Capacity M�, rmWv <br /> Distance to nearest: Well Foundation Property p Y�1 <br /> ��� <br /> LEACHING LINE ❑ No. & Length of lines TotalIen � NTY <br /> FILTER BED [_f Distance to nearest. Well Foundation flWAONMEWor <br /> -`•yl5 <br /> �iYiUiV <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 workmen'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 applicant mus all for all required inspections. Complete drawing on reverse side. <br /> Signed K Title: Date: <br /> (a�FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date D 9.3 Area z 1 t <br /> Pit or Grout inspection by Date Final Inspection by Date3 <br /> Additional Comments: !!!! llll <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> INFO FEE <br /> AMOUNT DUE AMOUNT REMITTED It CK 9 J RECEIVED BY DATE PERMIT NO. <br /> EH1321INEV.iin f4 C-0 <br /> 457 cO <br /> EH 14-M <br />