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SAN J AQ� UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION1I D <br /> 445 N SAN JOAQUIN, PHONE (209)468-342 <br /> P 0 BOX 2009 , STOCKTONr CA 95201 U <br /> 1 PERMIT E;EIRES 1 YEAR FROM DATE ISSU <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 1852 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> �,rt7� City Lot Size/Acreage i <br />'Job Address <br /> Address Phone <br /> Owner s Name <br /> Contractor t t„S. Address f" License No Phon rC�l� 1 <br /> TYPE OF WELL/PUMP �+ NEW WELL 7_') WELL REPLACEMENT Cl DESTRUCTION '1 Out of Service well <br /> / Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ (�j OTHER �,-l <br /> DISTANCE TO NEAREST SEPTIC TANK,> SEWER LINES �« DISPOSAL FL ROP LINE }� ' <br /> FOUNDATION ?1�Uf`t AGRICULTURE WELL�L � tDTHER WELL , `tP1T5/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS try <br /> ' 0 Industrial C Open Bottom ❑/Manteca Dra of Well Excavatron �•" Dia of Wan Casing / (LDomestic/Private r Gravel Pack JE (racy Type of Casing �� Specrfrcati <br /> k-1 <br /> I I Public Cl Other 71 Delta Depth of Grow Seal Type of <br /> Grout <br /> I I Irrigation Approx Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H P State ork p ne _ <br /> `� <br /> Well Destruction Material i Depth an ❑ Well Diameter <br /> Depth Filler Material i Depth <br /> PE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADOITION I I DESTRUCT1Oh1 ' I availablNot,wsystem <br /> nhin 200 teat J public sower is <br /> e <br /> Installation will serve Residence — Commercial^ Other <br /> Number of Wing units Number of bedrooms <br /> Character of soil to a depth of 3 feat 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 Lina <br /> t LEACHING LINE 0 No 6 Length of Innes Total length/size <br /> J <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS t I Depth Silo Number <br /> isumps LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> 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 Contractors hiring or subcontracting signature <br /> certifies the fonow ng I certify that in the performance of the work for which this permit is issued I snail employ persons subject to workman s compent:a <br /> lion laws of California <br /> The apphc#nt at Gall for all r aired +nspeGuons Complete tlrawing on reverse side <br /> r <br /> Signed Title Date <br /> DEPARTMENT USE ONLY _ <br /> DateArea <br /> Application Accepted by / <br /> t or Grout Inspection by t?^ < �1 4Z Final Inspection-by Date L/ Nr .Z_ <br /> i <br /> Additional Comments 1" -`�`' L M't ). s77 <br /> �� i^v .77 L i �L <br /> Applicant - Return allvopies to San Joaquin County Public Health SerNices RICE <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009 Stkn, CA 95201 <br /> ' FEE AMDUN7 DUE AMOUNT REMITTED CASH RECEIVED 3Y DATE PERMIT NO LJ <br /> INFO <br /> EK 13-24 trlev ii.si �� f'"� 4:r / L I �LA� VI7 I��- -� / 7 �• <br />