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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 O 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 <br /> /Public Health, Services. <br /> Job Address �` �'`� �/� ��fi(�� "'t City�� Lot Size/Acreage ?969— �7n <br /> Owner's Name ���"q^ �4e MPA SSL Address 5'�` 1 Z 2" Phone U` <br /> 11'n QcTrt), eo e T �l'7 <br /> Contractor Address License No� �� s�� Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 Monitoring Well C� <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 N <br /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [Komestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> 11 Public EI Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ` Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump <br /> H.P. -` State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth - -- — Wt-7,�' <br /> Depth Filler Material & Depth til (d A-j-11L_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial a 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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 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 workman'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 muall for all required i�umctions. omplete drawing on <br /> Signed X L Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by LQ S <br /> 4o `�L. Date N 2a-7 f/Z' Area <br /> Pit or Grout Inspection by Date Final Inspection by % V/� �"'� DatqI�2 <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> . EH13.24(REV.1/951 <br /> EH 14.26 <br />