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SAN JOAQUIN COUNTY.PUBLIC HEALTH SERVICES �■►r�■�c^ <br /> y\ 445 ENVIRONMENTAL AN IN, HONE (209)468-3420CI�■�1YGai�J <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 1n compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sen <br /> Joaquin County Public Health/Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name aT Address ---��• /'r 117� /E, '�- <br /> j� Reed <br /> J /� Phone <br /> Contractor 1' 4 r r F �ur'ti' Address 5 IC PL°(J1 Q?q UG>} � � �d-��� 7-D3q ' <br /> ---Y icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL %Z t` WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK 10l0 SEWER LINES I60f fi DISPOSAL FLD. PROP. LINE 2-01 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Ib0� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L-) industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 5uomestic/Private fel-Gravel Pack ❑ Tracy Type of Casing__ __ e Specifications <br /> i'1 Public I 1 Olhe, 11 Delta ` Dep h of Grout Sea! 4191t /K,-5- Type of Grout <br /> - <br /> I i Irrigation vt �Approx. Depth 11 Eastern _ Surface Seal Installed by <br /> Repair Work Done L] T p -- C6ri� l `� -�^k' <br /> p Type of Pum H.P. __f` ��Z_- State Work"Done._ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth -Filler Material & Depth- ` <br /> TYPE OF SEPTIC WORK: NEW.iNSTALLATION I I REPAIR1ADDITION'I I DESTRUCTION-I-1•(No septic system permitted if public sewer is <br /> r 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: ' ' Water table depth <br /> SEPTIC TANK_�..�_0 Type/,Mfg,. Capacity. t _!4q. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance,to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to-nearest: Well Foundation Property Line <br /> I :) <br /> SEEPAGE PITS I I Depth - ' Size Number <br /> SUMPS CI DiCuance to neatest:-- 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, 1 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 applica m st call for all required ins ctl ns. Complet yawing on reverse side. <br /> Signed t Title: �/!�^ Date: 3-17—Y3 <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by Date "t Area <br /> Pit or 9spection by r� J Date Final Inspection by Date °13 <br /> Additional Comments: <br /> Applicant - tteturn_all_copies to: San Joaquin County Public Health Service-s� <br /> w '•Eovlxonmental HealthTPermit/Services "" �" <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE '� AMOUNT REMITTED CASH CK RECEIVED BY DATA: PERMIT'NO. <br /> . EH t3-24 IREY.,,Nei rib 13• ✓� � �3_9 � <br /> EH t,•7e <br />