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SAN JOAQUIN COUNTY PUBLIC <br /> ENVIRONMENTAL PUBLIC <br /> DIyISIQNRVICES <br /> 445 N SAN JOAQUIN, PHONE ' <br /> P O BOX 2009 (209)468-3420 <br /> STOCKTON, CA 95201 No <br /> PERMIT EgpIRES 1 YEAR FROM <br /> APPlication is here (Complete iA Tr DATE ISSUED <br /> aPPlication is made to <br /> San Joaquin count 1P11Cate) <br /> Joaquin Co �e in Joaquin <br /> Y for a <br /> County Public Health Servi esh San J Permit to construct and <br /> Joaquin County Ordinance No. and/or install the work herein described. <br /> Job Address 5k9 and 1862 and the Rules <br /> L and Regulations This <br /> of San <br /> Owner's Name ci <br /> Ot Size/Acreage <br /> Contractor ddress,� �,J 3 <br /> PE OFWELL/PUMP: Address Phone ZdC <br /> NEW WELL D License Nol <br /> PUMP INSTALLATION D WELL REPLACEMENT p Phone, <br /> DISTANCE TO NEAREST: N <br /> SEPTIC TANK SYSTEM REPAIR D STRUCTIO ❑ Out of Service Well <br /> FOUNDATION SEWER LINES OTHER D MonitoringD <br /> INTENDED USE AGRICULTURE WELL DISPOSA FLD. well D <br /> TYPE OF WALL OTHER WELL PROP. LINE <br /> (_7 Industrial PROBLEM AREA -----__... PITS/SUMP$ <br /> Cl <br /> Domestic/Private D Open Bott m CON UCTION SPECIFICATIONS <br /> D Gravel Pac eca . Of We -Ex1"I Public . <br /> 1:1 Other D Tracy . __ aYation <br /> I I Irrigation Ype of Casing_ Dia. of Well Casing f <br /> fl Delta Depth of , U <br /> Repair Work Done D Approx. I 1 P Gout Seat Specifications <br /> Type of Pump tern Surface Se, b <br /> - Hy Type of Grout <br /> Well Destructionr t�{ <br /> D Well Diameter H. V <br /> Sealing Material i State Work Done_ <br /> TYPE OF SEPTIC Depth DePth ` <br /> WORK: NEW INSTAL Filler Material 6 Depth <br /> CATION I I REPAIR/ADDITION I I <br /> Installation DESTRU TION <br /> serve: Residence� Com o septic system <br /> Number of livin mercial permitted if <br /> g units: Other---__ ilable within 200 feet,) Public waver is <br /> Character of Number of bedrooms <br /> soil to a depth of 3 feet: <br /> SEPTIC TANK. <br /> Type/Mfg <br /> PKG, TREATMENT PLT,D <br /> Property Line <br /> Capacity Water table depth <br /> Distance to nearest: ~— No' Compartments <br /> Well Foundation Method of <br />.EACHING LINE Disposal <br />'ILTER BED D No. & Length 9 of lines --------_ Prop Len <br /> D Distance to nearest: _ <br /> Total length/size <br /> EEPAGE PITS ell Foundation <br /> JMPS 11 Depth Property Line <br /> U Distance ton Sire <br /> SPOSAL PONDS D earost: Well Number <br /> ereby certif ,.Foundation <br /> Y that I have prepared this a �— Property Line <br /> es and regulations of the PPlication and that the " <br /> me owner San Joaquin County work will be done in accordance With San Joaquin c <br /> or licensed a ant's si <br /> ploy any Person in such gnature certifies the followin <br /> vies the following- manner as to becorne g: "I certify that in the county ordinances, state laws, and <br /> 9- ,I certify that in the subject to workman's compensationawn of alit rn the w <br /> laws Of California.,, Performance of the work for whicthis Pelaws of California, work for <br /> which this Permit is issued, I shall not <br /> aPphca ust call permit is issued, I shall amp, -contracting <br /> hiring or sub-contractin <br /> I quire p Y Persons subject to workman's gom nature <br /> ed spe,Ctt s• om to drawing on reverse side. <br /> Penna- <br /> Title: <br /> cation Accepted by FOR DEPARTMENT USE Date: <br /> ONLY <br /> Grout Inspection by <br /> Oats 44�� <br /> anal Comments: Date Area <br /> Final Inspection b <br /> ` y , <br />)Plicant - RDate <br /> eturn all copies to: S —_ <br /> an Joaquin Co my Public Health Services We <br /> Environmental J <br /> 445 N San JOagluiienith Pexmit/Services -C <br /> INFO EE AMOUNT DUE ' P O Box 2009, Stkn, CA 95201' 4xy COP/ t ,� � jJ�?!� <br /> AMOUNT REMITTED CK of-,✓I ZZ� <br /> CASH RECEIVED BY a ve <br /> C& DATE ERMIT'N0. <br />