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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 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 is 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. f? / <br /> Job Address 2_00 a +w�- City Loa Lot Size/Acreage <br /> C-A <br /> Owner's Name moss, +(Io A 6aie o%ee-4, bN�. Address _ 5­103 5. A+s-Io gr 4r- 5 Phone Z -Cl 9 Z`14(011-5 <br /> F <br /> 11Jcts� Na�,M� <br /> Contractor_ Address -1P.rs.� � License No.Gprdoyall C !� C5� Phone ��' �o t <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well K <br /> DISTANCE TO NEAREST: SEPTIC TANK >aQ SEWER LINES 7Sor DISPOSAL FLD, r PROP. LINE —5:0 <br /> FOUNDATION 30r AGRICULTURE WELL ��OTHER WELL-2.50--' PITS/SUMPS 2- r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l� 1',�r�1� Dia. of Well Casing <br /> El Domestic/Private AGravel Pack ❑ Tracy Type of Casing_Se-kgrA 'i0 PUL Specifications <br /> I'1 Public I-) Other n Delta Depth of Grout Seal Q 1? fe¢1- Type of Grout 310 <br /> I I Irrigation 7jO-Approx. Depth I I Eastern Surface Seal Installed by D. I1; _ .._. <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Depth 1 ____ Filler Material 6aDe thh�'��Cer..e..�gy�O feed <br /> Well Destruction K Well Diameter rnc�. eP -.� a "' y <br /> S]_ +fie L� p (5w-G= N 4� <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ! I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted it public sewer is (� f <br /> available within 200 lest.) V <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 �V <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 subcontracting 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 applic u all requir inspections. Complete drawing on reverse side. <br /> Signed X Title: CLQ 12a 5 Date: <br /> R DEP USE ONLY <br /> Application Accepted by Date ` Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> 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 INFO �AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM11'N0. <br /> • EH13.14 TREY.s n 51 MW 7f �•� ti-- ALI <br />