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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 ISSUID <br /> (Complete in Triplicate) <br /> to San Joaquin county for a permit to construct and/or install the work herein described. This <br /> Application is hereby made <br /> application is made in <br /> nHcompliance with San Joaqui <br /> n County Ordinance No. 51+9 and 1862 and the Rules and Regulations of Sart <br /> ealth <br /> ces. <br /> Joaquin County Pu <br /> ®LA 49.SGity �Nlpo Lot Size/Acreage <br /> Job Address ...7 <br /> 121tr�w►c3 q 27_0 Phone <br /> Address ' <br /> Owner's Name (Lk-3160 <br /> r0 -7— <br /> `�C� `'j ,S t License No. � � Phone ' <br /> Address 1 <br /> Contractor WELL REPLACEMENT ® DESTRUCTION ❑ Out of Service Well C1 <br /> NEW WELL ❑ OTHER ❑ Monitoring well Ll <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR C� <br /> PUMP INSTALLATION <br /> SEWER LINES �-�— DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �--- OTHER WELL PITS/SUMPS <br /> FOUNDATION �-- AGRICULTURE WELL <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE <br /> O Open Bottom ❑ Manteca Dia. of Well Excavation <br /> n Industrial Type of Casing_ Specifications <br /> 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout ]� <br />` Il Public <br /> I:1 Other n Delta Depth of Grout Seal <br /> I } Irrigation _.Approx. Depth i I Eastern Surface Seal Installed by <br /> CL H P State Work Done <br /> Repair Work Done 0 Type of Pump Sealing Material i Depth <br /> Well DestructionWell Diameter Filler Material a Depth <br /> _ 'Depthc SY518tyl n <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I } alvailablerwit in 200 feet.) it public sewer is `l <br /> Installation will serve: Residence_.__ Commercial — Other,�-- <br /> Number of living units: Number of bedrooms a Water table depth <br /> Character of soil to a depth of 3 feet: <br /> D TypalMi Capacity__ �---- -- Na. Compartments <br /> SEPTIC TANK g Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE D No. & Length of lines property Line <br /> FILTER BED [1 Distance to nearest: Well Foundation <br /> -- <br /> SEEPAGE PITS 11 Depth Size Number <br /> property Line <br /> t SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Cl <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 /> f rules and regulations of the San Joaquin County <br /> agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I she not <br /> Home owner or licensedsub-contracting <br /> employ any cert fies the nature <br /> fo following: <br /> 1 cermtiify that n the performance oforna subject nner as to b8cthewok fofiwh ch this permit is issued, I shall employ personssubjectto workman's aampensa• <br /> tion laws of California." <br /> Theapplicant m all for all required inspections. C plate drawing on rse ida. <br /> Date: <br /> Signed X Title: <br /> FOR DEPARTMENT USE ONLY 'X4 <br /> 1 <br /> .- Date �� /-�'��—.. rea <br /> Application Accepted by <br /> n by Dat <br /> Pit or Grout Inspection by Date -- <br /> Final Inspectio <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Environmental oHealth unty ublic Health vices <br /> Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> K RECEIVED BV HATE PERMIT NO. f <br /> i FEE AMOUNT DUE AMOUNT REMITTED SAT <br /> W O <br /> . EM 13-24{REV, 51 r <br /> EH 14.26 <br />