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SANrICES <br /> ' / < <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 /> ith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of an <br /> application is made in compliance w <br /> Joaquin County Public Health Service+. <br /> City � Lot Size/Acreage <br /> Xiob Address rQ <br /> 7� dress �` o <br /> �� — Phone <br /> Owner's Name i <br /> Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F.1 OTHER p MoDESTRUCTION Cl Out Monitoring Well C7 <br /> of Service Well ❑ } <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES D POSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU WELL OTHER WELL. PITS/SUMPS <br /> INTENDED USE TYPE OF WELIL PROBLEM AREA CON ION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca of Excavation Dia. of Well Casing i <br /> Type(:l Domestic/Private ❑ Gravel Pack ❑ Tracy T Yp of Casing— Specifications j <br /> I'! Public <br /> C.1 Other a to Depth of Grout Seal Type of Grout <br /> I I Irrigation T,_ Approx. M pth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump I H.P. State Work Done <br /> Well Destruction ❑ Well Diameter � <br /> Sealing Material & Depth <br /> Depth Filler Material ii Depth 90 <br /> TYPE OF--SEPTIC WORK: NEW INSTALLATION I I REPAtR/ADDITION I I DESTRUCTIOINo septic system permitted if public sewer is <br /> 043 <br /> vailable within 200 feet.l <br /> Installation will serve: Residence "Commercial— Other <br /> piv <br /> r f e s �Far� IPxd; <br /> et�3 eet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PK �l expired without ! Method of Disposal <br /> Complet d r l ift"work being- <br /> Weil Foundation Progeny Line <br /> rirW I�t�r } tst�f s j Total length/size <br /> LEfltk[sYt1�7tEg3 t"I� :L� Le ?5 <br /> FILTER BED ❑ Distance to nearest: Well= Foundation Property Line <br /> t,,� .�.�.,� <br /> SEEPAGE PITS I I Depth •t Sire � Nurtiber � <br /> SUMPS L! Distance to+nearest: Well Foundation Property Lino <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, I shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractors 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 compsnsa r <br /> tion laws of California." I <br /> 1, The applican must call for all required inspections. Complete drawing on reverse side. q <br /> Signed X % f Title: . i9 L"J _ Date: <br /> 9 <br /> F R DEPARTMENT USE ONLY «� p t <br /> Application Accepted by Date <br /> Ou��l'� [ �_ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments,- <br /> Applicant <br /> omments:Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA iH RECEIVED BY DATE PERMIT'NO. <br /> INFO +�/ // � ++'']],�'] <br /> . EH13-211REV.tinSi / q' ��� I4 ,� ` /����� <br /> EH 11.25 <br />