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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEO FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Ss hereby made to San Joaq•Sn County for a permit to construct end/or install the work herein described. This <br /> application is aide in compllan_= with San Joaquin County Ordinance No. 1,49 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Healthh flervl".. 4' <br /> !'�ffX-[Zl�- �- <br /> Lot Site/Acreg <br /> ae r <br />'� JO ddrsss (� Cir y <br /> CO <br /> / dress �_1Z`IL.._ <br /> TYPEPE OF WELL/PUMP NEW kbnitoring Yell <br /> WELL � WELL REP�_ACEMENT (1 DESTRUCTION ❑ Out of Service 3/ell <br /> LI <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER c7 ' <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> 0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N; <br /> 7 IndustnN U Open Bottom ❑ManbD' <br /> ca D a of WeII Excaysuon Dia.of Well Casing <br /> g_._____ 5 ..`r canons � <br /> r 1 mestic/Private Cl Gravel Pack D Tracy Type of Casing - TV. -Grout <br /> Public I"1 Other fl Delta Depth of Grout Seal <br /> ImUsocin ,—ApProx. Dept East n dace Soul Installed _— <br /> Repair Work Done '> Type of Pump4r- Z <br /> r <br /> �_ H.P. S <br /> Sealing Material i Depth '! <br /> Well Destruction O well Diameter 7�^ / 7Sller Material a ,Depth 1 <br /> Depth [� <br />` TYPE OF SEPTIC WORK: NEW:NSTALLATION; I REPAIR/ADDITION I t DESTRUCTION I 1 (No teprrc system pormNted i!publ.c sewer u t <br /> &variable within 200 lest.), <br /> Installation will s,rver Residence_ Commercial_ Other <br /> Number of living units:_ Number cf bedrooms , 1 <br /> Water table depth ! <br /> Character Of wit to a depth of 3 feat: t <br /> Capacity _ No. Compartments <br /> SEPTIC TANK O Type/Mfg Method of Disposal t <br /> PKG. TREATMENT PLT.D <br /> Distance to nearest: Well Foundation Property Lina <br /> j <br /> LEACHING LINE Ll No.6 Length o1 lines Total length/size_- <br /> FILTER BED O Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire _ Number_— ff <br /> — <br />"` SUMPS LI Distance to nearest Well Foundation_ Property Lina <br /> DISPOFAL PONDS O <br /> I hereby certify that I have propare1 this application and that the work will be done in accord:nee with San Joaquin county ordmancef,state laws,and <br /> rules and regulations of the can Joaquin County <br /> Home owner or Irconlad agent'&signature cartlfist the following:-I ce.'tity that in the performance of the work for which this permit is issued.I shall not <br /> employ any parson in such manner a to become sublsct to workman's compenaatinn lows 0!California."Crintracior's hiring or sub-cvntracting signature <br /> empl y tits perfollson in u h ma that s iM perfgrnlance of the work for which Ihit permit is issudd.I shall employ persons subject to workman's compen&a- <br /> lion laws of California" <br /> The spplictq!��st call 1 on <br /> I r <br /> inapacti &.Complete dr Twing on rave <br />-� `�nnyyt3F��a /� Date: (/X,_ ✓„Ll <br /> r � <br /> rtEPARTMENT USL .NLY <br /> _ ^1\34' <br /> Date_���� Area <br /> Application Accepted by 1.G� <br /> Pit o:Grout Inspection by <br /> Date Final IOspeC tion by � Dole <br /> Add4k;ASI Comments: - <br /> Applicant - Return all copies to: Sen Joaquin County Public Health Sorvlce9 <br />_ Gnvi ronmen tel Health Pet; ten <br /> Box <br /> 445 N den Joaquin, P O Box 2009009,. Stkn, CA 95201 <br /> FEE AM'✓UNT AE Mi7T E0 K AECEIYED SY D.+'E PERMIT NO <br /> AMCUNT DL: l:A$H <br /> 1 INFO <br /> [h'3 raresv. <br /> t H .y [[[ <br />