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rrZ� <br /> f <br /> 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 /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (Complete in Triplicate) <br /> Application is hereby made.to Sea 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. <br /> City Lot Size/Acreage <br /> Job Address <br /> jyI.aej e !+e r Phone 0 �� <br /> + Owner's Name Address <br /> Contractor <br /> jvE( Nr Address /h � r License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ out of Service well ❑ <br /> iOTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> t n Industrial C3 Open Bottom ❑ Manteca Pia. of Well Excavation Specifications <br /> Fa Domestic/Private ❑ Gravel Pack CeTracy Type of Casing_. Type of Grout <br /> i I'I Public Cl Other 171 Delta Depth of Grout Seal <br /> f i } Irrigation —Approx. Dep I Eastern Surface Seal Installed by <br /> Repair Work Done U Type at Pump s�— H.P. { Stara Work Done <br /> Sealing Material Depth <br /> Well Destruction ED Well Diameter <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION [ I DESTRUCTION I I (No septticailable systithin m per <br /> feetil�ed if public sower is <br /> Fr <br /> Installation will serve: Residence— Commercial — Other y, <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Capacity <br /> SEPTIC TANK- 0 Type/Mfg � <br /> PKG. TREATMENT PLT. Cl MiToYiiSpq t� <br /> Distance to nearest: Well Foundation Propert U <br /> fill 4 -1. tnmn <br /> E LEACHING LINE ❑ No. & Length of lines Total lengthlsize J <br /> FILTER BED ❑ Distance to nearest: Well Foundation P�PC'G� �GES <br /> J <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> :e <br /> ­,_DISPOSAL-PONDS Q- =- <br /> 1 hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature oenifies the following: "i certify thar 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 signatwe <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 mus II for all required inspections. Complete drawing on reverse side. <br /> Signed '� Title: '� Date: <br /> I FOR DEPARTMENT USE ONLY <br /> � Application Accepted by Dare - Area d <br /> i Pit or Grout Inspection by Date µ 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 Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK JV <br /> H - RECEIVED BY O TE " PERMIT'N0. <br /> . EH 1�•2�[flt2V. /H 51 � / <br /> EH 11.26 <br />