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PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 F E B 18 1993 P O BOX 2009, STOCKTON, CA 9520 . SAN JO FALT SERVICOIUNE PERMIT EXPIRES Z YEAR FROM DATE ISSUED P>J�LIr~hi E:RLTh15��1�ICfwS ENVIRONMENTALHEALTHDIViSiON � (Complete in Triplicate) ,M tlsa Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein des ribed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �RgA/z & "Ic .p City Lot Size/Acreage Owner's Name Address Phone � Contractor Address License No. ate Phone TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �HERWELL__ PROP. LINE FOUNDATION AGRICULTURE WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing El Domestic/Private Cl Gravel Pack cy Type of Casing_ Specifications I(I Public is Other I-1 Delta Depth of Grout Seal Type of Gout t I I trhoation —Ap Depth—['I Eisiern� Surface Seal Iristalted'by , Repair Work Done U Ty of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material ti Depth 1 it, Depth �� Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION-l'I DESTRUCTION INo septic system permitted if public sewer is k '!` available within 200 feet.} Installation will server Residence._.—. Commercial_ Other` ¢ .. f f Number of living nits: J�Number of bedrooms . -E.,r Character of soil to a depth of 3 feet: -i Water table depth SEPTIC TANK ❑ Typol/Mfg __ '_ `_, _- Capacity No. Compartments PKG. TREATMENT PLT. Cl �l M; �' # �! Method of Disposal_ Distance to nearest: Well Foundation Property Line t LEACHING LINE Cl Nolliii Lengtir,t f lines ''Total length/size FILTER BED ❑ Distance,to nearest, t Well Foundation F" Property Line SEEPAGE PITS 11 Depth _¢ � Size - Number SUMPS i l Distance to nearest:, Well Foundation Property Line DISPOSAL PONDS ❑ „I[ ti I hereby certify that I have prepar& this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County 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 employ any person in such rnanner'I'as'to become subject to workman's compdn-sation laws of-California." Contractor's hiring or sub-contracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant m call for all req lire ' cti '+C;Mplete'drawing on reverse sid r Signed X +. Title: Date: 69 A.�p� R EPARTMENT USE ONLY Appl' Ion�AcclptdLby 014q�L . Date ` Area Pit or Grout Inspection by Date Final Inspection by CILAI, w Date Additional Comments: I� I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAT INFO CASH E PERMIT'N0. + Eh 13.24(REV.I 1 n 5t EH 1 .26 I 71- IE r