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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION , <br /> 445 N SAN JOAQUIN, PHONE (209)468-34120 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby ms4e 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 /> J ��� C[oaquin County Public Health Services. ^f — <br /> /} -7 r� Lot Size/Acreage <br /> + Job Address <br /> pf 1 i Cit <br /> { � - Phone �!� <br /> i O+rirner's.Name cess �] <br /> License Nv�Z- <br /> Contract r Address <br /> TYPE Of WELL/,PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION C} Out of Service,Well ❑ <br /> 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' " DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> ,,�--•-.L-INTENDED-USE= STYPE OF-WELL--PROBLEMAREA` CONSTRUCTION SPECIFICATIONS <br /> t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia-" !,Well Excavation- - Dia. of Well Casing <br /> , T e of Casing-- "- - Specifications• - <br /> _ C.1 Domestic/Private, - C]_Gravel Pack- C1 TrarK) <br /> cy - YP <br /> U�Public 1-1'Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation. .—Approx. Depth I I Eastern cSurfiee Seal Installed by <br /> ._'Repair Work Done L] Type of Pump H.P. r x„ " ' State Work Done _ <br /> Sealing Material & Depth-':: <br /> Well Destruction ❑ Well Diameter i <br /> Depth ' lal,& Depth <br /> r TYPE OF SEPTIC 1NORK� LVV INSTALLATION I ' ' EPAIR ADDITION DESTRUCTION I i {No septic system permitted if public rawer is <br /> } "4-r available within 200 feet.) <br /> Installation will,serve: Residence Commercial— Other <br /> Nur ber."of living units: `` Number rooms Y <br /> CheracteF of soil-to a depth of 3' <br /> feet: <br /> table depth <br /> j = <br /> SEPTIC TANK i ❑ Type/Mfg Capacity No-compartments <br /> Method of Disposal <br /> PKG.TREATMENT PLT. Gl w <br /> ` Distance to nearest: Well Foundation PropartyTLine <br /> i 5 <br /> LEACHING LINE ❑ No. & Length of lines t,- { -Total length/size <br /> FILTER BED ❑ Distance to nearest: Well F, dation r Property One <br /> # SEEPAGE PITS I I Depth Size Number <br /> r <br /> SUMPSt ' <br /> Distance to nearest: We .. f Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify.that I have prepared-this application-and that the-work will-be-done-inuaccorrdance-with San Joaquin county orddinances, state laws, and <br /> +' t <br /> rules and'regulMbUris of,the San Joaquin County "' ` --a <br /> Home owner of 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 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 o alifornfa." t <br /> The applican m t call for req "r inspections. Complete drawing an'averse rid <br /> Signed Title: �' Date. . <br /> FOR DEPARTMENT USE ONLY <br /> 111 "h �1 <br /> l `y�rJ�(, <br /> ` Application Accepted by � � ._ Date !^• /L -`-Area <br /> Date Final Inspection by f�r % Date�1 } <br /> It�Ir Grout Inspection byAdditional Comments: s <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services ' <br /> - 445 H San Joaquin, P O ox 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTE CK ECEIVPP 8Y D . <br /> TE _ PERMIT NO. <br /> INFO <br /> + EH11-21{REV.1ixsl <br /> CH 111.26 <br />