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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 /> C��n � � PERMIT EgPIRES 1 YEAR FROMDATE ISSU <br /> Ve Pu, ID y <br /> 1' (Complete in Triplicate) <br /> tall <br /> work <br /> in <br /> Application is hereby made.f:oaSan with SaneJoaquinocountyrordinancemit to nNo. 549struct gand o1862aand the eRules and FRegulations dof Sans <br /> application is made in comp. <br /> nce <br /> Joaquin Co Public liealt Service int gaze/Acreage <br /> ��� ®/' L­�77_�Z <br /> !( <br /> Job Address ` <br /> C / S <br /> vXIAe✓a�Addresd hone <br /> Owners Name�'r <br /> License N¢� Phone <br /> AddresWell 0Well <br /> Contractor WELL REPLAGEM> N7 ❑ DESTRUCTION ❑ put of Service Well C1 <br /> NEW WELL ❑ OTHER ❑ Monitoring <br /> TYPE OF WELLlPUMP: SYSTEM REPAIR Id <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES �---- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPT�C TANK --� PITS/SUMPS FOUNDATION <br /> AGRICULTURE WELL OTHER WELL--� <br /> INTENDED USE TYPf OF WfLL PROBL�EA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open.Bottom Manteca Dia. of Well Excavation <br /> i� Industrial Specifications <br /> ❑ Tracy Type a! Casing_ <br /> Ca Romestic/Private Casing— <br /> L1 Pack Type of Grout <br /> [:1 Other n Delta Depth of Grout Seal <br /> i6 Publicµ Surface Seal Installed by <br /> �,h pprox. Dep ,�I Eastern <br /> IEA5�� <br /> I I Irrigation �, H P State Work Don /� <br /> ' Repair Work Done TYPel�of Pump (J) <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter ---- Filler Material i Depth <br /> peptll <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITIDN I I DESTRUCTION l 1 availableFed if public sewer is <br /> within 200 feet.) <br /> f Installation will serve: Residence , Commercial Other-------- <br /> Number of living units: Iw Number of bedrooms Water table depth <br /> Character of 8011 to a depth-of 3 feet: Capacity---- No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 11Foundation Property Line <br /> Distance to nearest: Wall <br /> y Total length/size <br /> LEACHING LINE Cl 1Vo; Length of Eines Foundation �— Property Line a <br /> l Welt <br /> FILTER BED D Distance to nearest: <br /> Number <br /> SEEPAGE PITS 11 Sue Depth Property Line <br /> SUMPS E1Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ II <br /> I hereby certify that l 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 SBn.Joaquin County <br /> a signature certifies the following: "I certify that in the performance of he work for which this permit is issued, !shad <br /> Home owner or Licensed agenton not <br /> employ any person in sue <br /> in <br /> certify that n the performance cof to <br /> wok for which this permit is issued, shall employ persons rsubject�o wc°kme t!sg°rgpensa <br /> certifies the following: _ <br /> tion laws of Cal' , <br /> The appf can must c „for sillrequired ctio Com ete thawing on rev side• <br /> Date: . <br /> Title: • •; <br /> Signed <br /> !� OR DEPARTMENT USE ONLY r' <br /> Date I- L Area <br /> �._ <br /> Application Accepted by <br /> I� Final Inspection by Data <br /> r Pit or Grout Inspection by <br /> Date <br /> Additional Comments: lth r <br /> Applicant - Return all copies to: San Joaquin blic Hem <br /> Environmental oHealth unty upermit/Services <br /> vices <br /> 445 N San Joaquin, P 0 Bax 2009, StXn, CA 85201 <br /> l <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO r <br /> . EH 1324 IREv.1 i w s <br /> f <br /> EH 14.26 <br /> f I� -- <br />