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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 Public Health Be lees. <br /> Job Address r � City Q , Lot Size/Acreage �AL 14e-- . <br /> Owner's Name Address S �'� Phone26 2 6Z_ <br /> Contractor_ Address '1 License NoJ��� Phone <br /> TYPE OF WELT:/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> l PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ 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 PaOLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom" anteca Dia. <br /> off Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack Tracy SCAN JOAQCOSY.PMMC HEALTH SOY.Mns <br /> V1 Public Cl Other n Delta 1MWNA*N I.HEALTH DIVISI # <br /> O�pe of Grout (v <br /> I I Irrigation ._.._..Approx. Depth..,I•I EasternSkSJpLV t,�er7iT.b_y ` <br /> Repair Work Done U Type of Pump H.P. �7 <br /> Well Destruction D Well Diameter �, Sealing Material & Depth <br /> t Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW-INSTACLATIO`N-I-3—REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sower is <br /> +Y-�-- available within 200 feet.1 <br /> Installation will serve:. Residence Commercial— Other J <br /> Number of living units: Lk-__ 'Number'of _roo s D r <br /> Character of soil to a depth of'3 feet: Water table depth <br /> SEPTIC TANK ` C Typa/Mfg Capacity �6!?L7 No. Compartments '2, <br /> PKG. TREATMENT PLT. ❑ »y - Method of Dispos I <br /> Distance to nearest: Well Foundation Property Liner <br /> LEACHING LINE Cl No. & Length of lines 7atal length/size <br /> FILTER BED ez�`Distance to nearest: Well 450 Foundation _ZA:i Property Line <br /> SEEPAGE PITS 11 Depth g _Size Number <br /> SUMPS _i*- Distance to nearest: 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, anc� <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 subcontracting 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 appli t must call for all req ed in coons. Complete drawing on re <br /> mit/ - <br /> Signed Title: - Date:` <br /> F DEPARTMENT USE ONLY µ <br /> App' tion Accepted by __ ,e .._ Date W� �— Area Z, <br /> r Grout Irfepection by / / , �"'Dilate r Z Finel Inspection by Date <br /> Additional Comments: 72, — .- _ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> 445 NoSanJol Health Permit2Services <br /> 445 N San Joaquin, P p Box 2009, 8tkn, CA 95201 <br /> FEE <br /> INFO ttAMO/UNT DUE AMOUNT REMITTED GASH RECEIVED BY TE PERMIT'N0. <br /> r E 13.21(REV.i/n51 <br /> EHH 11.2tl r L L1lQ l <br />