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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> f 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 Public Health Ser ices. <br /> Job Address (,�j Q City ,/�11 �, ��� Lot <br /> �Si�ze/Acreage <br /> Owner's Name ` 2 �L° Address /'7�C) A,l Ls�'d�1.2_L Phone <br /> Contractor Address 8 License No. Phone <br /> TYPE OF WELL/PLIP: NEW WELL ❑ WELL REPLACEMENT . DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O Monitoring Well C7 <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 <br /> * Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'I Public 1-1 Other n Delta Depth of Grout Seal T pe of Grout <br /> f <br /> I I Irrigation —Approx. Depth I I astern Surface Seal Installed by <br /> Repair Work Done (J Type of Pump ( H.P. t State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth CN <br /> j <br /> Depth_ r Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line (/ <br /> LEACHING LINE C) No. & Length of lines Total length/size <br /> FILTER BED O Distance to.nearesL'. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to'nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> I hereby certify that I have prepared this application'end 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 ps n in such manner as to become subitfcrto workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f lowing: "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 law of ornia." <br /> The apple n must call for all quired ins coons. Complete drawing o ray ide. <br /> F { � .--- <br /> Signed X Title: Date: <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date�2 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services Vk <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDC H RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> l <br /> . EH13.21 1NEV.v e s1 s <br /> EH 11.21 • ^T �/" 9? 1 <br />