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' 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1V � <br /> ENVIRONMENTAL HEALTH DIVISION I <br /> 445 N SAN JOAQUIN, tPHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> made to San Joaquin County for a permit to construct and/or install <br /> Application is hereby the work herein described. This <br /> ce®pllance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is hermade-in <br /> Joaquin County Public Health Bervicea:-4.1. <br /> City e Lot Size/Acreage <br /> Job Address <br /> l C ?4 , Phone 43 00 <br />(f Owner's Name <br /> �r Addresses, '� <br /> I Gflr}y Y Address , L� nseNo.- o7ZPhone <br /> Contract <br /> y r S <br /> I TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT ( 1 DESTRUCTION Gl Out of Service Well C <br /> i PUMP INSTALLATION [�� SYSTEM REPAIR O <br /> OTHER ❑ Monitoring Well <br /> Ia SEWER LINES _ DISPOSAL FLD, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �O <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> p ,Cl Industrial pen Bottom 0 Manteca Dia. of Well Excavatio <br /> Dia. of Well Casing <br /> I Type of Casing_ Specifications <br /> omestic/Private ❑ Gravel Pack ❑ Tracy m T pe of Grout <br /> I'I Public i-1 Other i-1 Delta Depth of Grout SeW <br /> �' 11 ' --�.Appiax. Depth I I Eastern Surface Soul Installed by <br /> I I Irrigation '` - <br /> �, L H P �3- t State Work Done <br /> Repair Work Done L7 Type of Pump Sealing Material & Depth <br /> k <br /> Well Destruction C1 Well Well Diamete -Depth Filler Material Z Depth <br /> tys <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDIT40N f I DESTRUCTION l I alvailableseptic <br /> wi hin 200 feert�ed it public sewer is <br /> Installation will serve: Residence_ _ Commercial— Other <br /> Number of"living units: Number of bedrooms Water tablrr depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK-, lJ Type/Mfg Capacity--- No. Compartments s� <br /> PKG. TREATMENT PLT.❑ Method of Disposal y <br /> I <br /> Distance to nearest: Well Foundation.. Property Line <br /> 1. T <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> f SEEPAGE PITS n 11 Depth Size Number <br /> I LI Distance to nearest: 'Well Foundation Property Line <br /> SUMPS <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, an. T <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, 1 shall not <br /> e omo o ny person in such manner as to become subject to'workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cartif!as 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 must call for ulred inspections. Complete drawing on reverse side. <br /> Title: �� — - Date: ^� <br /> Signed X - <br /> F DEPARTIIilEN7 USE ONLYPit or Inspection by 4r, <br /> Application Accepted by p <br /> Date Area_y <br /> ate& Z Fina! Inspection by Data (S! f_�1L <br /> ro t �p <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 Box 2009, Stkn, CA 95201 <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> . EK 13-24(REV.riKs) / �,• <br /> Z73 J <br /> EH 11-2e r _ <br />