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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 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 thervork herein described. This <br /> application is made in cotopliance with San Joaquin County Ordinance no. 549 and 1$62 and the Rules and Regulations of flan <br /> Joaquin County Public Health s�errvices. <br /> Job Address J J <br /> .�� <br /> City /Lot-Size/Acreage <br /> Owner's Name , � ,07 Address r. r <br /> Phana We <br /> Contractor Address <br /> TYPE OF WELL/PUMP: License No. e / Pho <br /> W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ out ofWell ❑ <br /> PUMP INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR C1 OTHER ❑ Monitoring Well <br /> � f <br /> FOUNDATION /J / WER LINES _�� DISPOSAL FLD. �` PROP. LINE j <br /> AGRICULTURE WELL OTHER WELL === PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom 4 ❑ Mane <br /> Dia. of Well Excavation Dia. of Well Casing <br /> DomesticlPrivate Gravel Pack El Tracy T <br /> i'l Public 621 pelta Type of Casing_ ` Specifications <1 <br /> fa Other J,� Depth of Grout Seal <br /> I I irrigation ---� �� Type of Grout <br /> .Appr , Depth I 1 Eastern Suace Seal Installod byAgn <br /> Re air Work Done U T S / i� <br /> p Type of Pump , H.P. _. <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth Stats Work Done <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I 1 (No septic'system permitted if public sower is <br /> Installation will serve: Residence— Commerciale Other ,_ �- available within 200 feet.) <br /> Number of living units: Number of bedrooms �? <br /> Character of soil to a depth of 3 feet: r € <br /> SEPTIC TANK. ❑ Type/Mfg Water table depth-- <br /> PKG. TREATMENT PLT. 0 Capacit �� No, Compartments <br /> Method of Dispdsat, <br /> Distance to nearest: Well Foundation <br /> -- �—_ Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FiLTER BEDTotal length/size <br /> Ll Distance to nearest. W011f <br /> Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size - <br /> SUMPSNumber <br /> LI Distance to nearest: Well Foundation r <br /> -DISPOSAL PONDS ❑ Property Line <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, f 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 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 applicant alb.3 f r" i requir titins. Complete drawing on rover se=sido. r <br /> Signed �. <br /> itle. dmC—.� Date: <br /> FOR DEPARTMENT USE O Y F <br /> Application Accepted by _} <br /> Date Z Area G �. <br /> Pit or GInaioection by Data It 1L -Final I <br /> nspection by Date <br /> Additional Comments; _ibrni l ,. <br /> Applicant-- Returmal-I•copies-to.:^^San'-Joaquin'Countyublic-Health <br /> -Services—""" <br /> Environmental Health Permit/Services w � <br /> 445 N San Joaquin, p 0 Box 2009, Stkn, CA 95201 <br /> FEE S_ . ' ".-- <br /> INFO AMOUNT DUE AMOUNT REMITTED t CI(1 ' ' RECEIVED BY <br /> !� CASH DATE PERMIT'NO. <br /> EN 13.74[REV,1/a+51 " ©� <br /> EH 14-20 - �D� r ,-2 C �V <br /> -. .,, .,.-�. __ ..yam, � .�--_•. _ _ _. s �..o _ .. , <br />