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SAN IQUIN COUNTY PUBLIC HEALTH t iVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 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 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> wob <br /> 4�r CJJ� Lot Size/Acreage Address �� City a y cr Address G 7 �U.e"�`'t -f-Phone <br /> Apwner's Name <br /> Contractor V- 1-Z-121 '" _Add res - A License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL {'~ A ENT ❑ DESTRUCTION m Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ Y TE OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK �_�� INES f�I LL PROP. LINE <br /> FOUNDATION G ICU�ti OTH moi:' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR EM AGS G 0, P NS <br /> Ll industrial ❑ Open Bottom, D nteci$ jlj�'O aa.,of e'f x v Dia. of Well Casing <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type _ Specifications <br /> I"1 Public 1-1 Other 11 Delta Depth of Grout Sea 131Ql7 _ Type of Grout <br /> I I Irrigation. —.Approx. Depth t I Eastern Surface Sou_I Installed by <br /> ;. Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> I I DESTRUCTION I INo se tic system permitted it public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION P <br /> available within 200 f t.l <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 labia depth <br /> SEPTIC TANK © Type/Mfg Capacity <br /> No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Well oundmi n Property Line <br /> Distance to nearest: ._.-.��F <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to near t: Well Foundation Property Line r <br /> SEEPAGE�So <br /> Depth Size Number <br /> SUMPSDistance to nearest: Well Foundation - - Property Line <br /> DISPO <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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatufe, <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: �s�WA A ___ Date: Z-Y <br /> EPARTMENT USE ONLY <br /> Application Accepted by % date - AreaiJ <br /> 1 , <br /> iPit or Grout Inspection by �= Date Final Inspection by Date <br /> i� <br /> Additional Comments: <br /> Applicant - Return all copiesi,to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> ms, 7 <br /> AMOUNT DUE AMOU T REMITTED CA H RECEIVED BY OATE PERM17'N0. <br /> ` . EH13.24{REV,tiRs1 voe'EH 14.20 <br />