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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DI46$-3420 <br /> 445 N SAN JOAQUIN, PHONE (209) <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> v <br /> n t, {/'1 PERMIT F�%PIRES 1 YEAR FROM DATE ISSUED <br /> � epi` (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 /> n county ordinance No. 549 and 1562 and the Rules and Regulations of San <br /> application is made in compliance with San Joaqui <br /> Joaquin County Public Health Services. ` <br /> City S o Lot Size/Acreage <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Ns- _J 2 r/� <br /> 4WJ-4e <br /> Addres� <br /> License M QTD Phone <br /> Contractor WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well <br /> TYPE OF WELL/PUMP: NEW WELL 71 OTHER D Monitoring Well <br /> El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST; SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />[ INTENDED USE — Dia. of Well Casing <br /> Cl Industrial Cl Open Bottom Cl Manteca Dia. of Well Excavation Dia.SpecificationsWellCa <br /> �[Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ <br /> :� Other <br /> i'I Public I <br /> Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx.•Depth I I Eas[ern Surface Seal Installed by <br /> of Pump -s WP. � _ State Work Don <br /> Repair Work Done >' Type Sealing Material 8 Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I fiEPAIRIADDITION i I DESTRUCTION I 1 availabPelwithin 20c system Q feg`ned it public sewer is �t <br /> I Installation will serve: Residence Commercial _ -Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK.. ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 0 property Line <br /> f Distance to nearest: Well Foundation <br /> LEACHING LINE ❑ No. & Length of lines _,Total length/size <br /> s FILTER BED ❑ Distance to nearest: Welt Foundati. L Property tine ` <br /> I <br /> SEEPAGE PITS lI Depth Size Number <br /> � . <br /> SUMPS LI Distance to nearest: Well Foundation -- �Property Line� . <br /> DISPOSAL PONDS ❑ <br /> ill be done in accordance with Soman Joaquin county ordinances, stats laws, an <br /> I hereby certify that 1 have prepared this application and that the work w , <br /> rules and regulations of the San Joaquin County <br /> I certify <br /> I signature certifies the following: " y that in the performance of the work for which this permit is issued, l shah not <br /> Homs owner or licensed agent's sign <br /> employ any person in such manner n to become subject [o workman's compensation laws of Cslifornia." 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 persona subject to workman's c Dense <br /> tion laws of C ia." <br /> Thea cant t call for all re uir 1 pections Complete drawing on rev s ide. <br /> Title: Date: <br /> Signed -• <br /> �* DEPARTMEN7�USE-QNkY "`^"- --- "" -- ^Z <br /> r !Date �— -- Area <br /> Application Accepted by C`"' �. �► t <br /> "- Date !� <br /> I Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaqu , O Box 09, Stkn, CA 95201 <br /> CKEIVED BY DAT PERMIT N0. <br /> FEE AMOUNT DUE AM NT REMI ED H <br /> } INFO <br /> f n <br /> k EH 13m24 IREV. <br /> EH 11.20 <br />