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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..YEAR FROM DATE ISSUED <br /> (Complete Jn 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Heal t ervi j s /1 <br /> r A r b (� <br /> Job Address City Lot S14e/Acreage _ <br /> q 2 <br /> Owner's Name Address '* t �Pfione `I!J r! <br /> r n ( J ] License Nd. < u Phone <br /> 2,2 <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REACEMENT. F) DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYS7 M REPAIR J❑ r OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLq. POP. LINE <br /> 1 FOUNDATION, AGRICULTURE W 4 F OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA N RUCTION SPECIFICATION <br /> 5 industrial ❑ Open Bottom ❑ Manteca Dia. f Well Excavation Dia. of Well Casing <br /> [D Domestic/Private ❑ Gravel Pack ❑ Tra Typ of Casing_ Specifications ( � <br /> V <br /> I 1 Public to Other alta Dep h of Grout Seal Type of Grout i <br /> I I Irrigation Approx. Depth L I Eastern 5u ace Seai in Ind by I <br /> Repair Work Done' U Type of Pump r' H.P. " State W4-Don. n <br /> Well Destruction „ ❑ Well Diameter <br /> sealing-Materlal_i9-Depth t <br /> Depth w ,• ;t Filler Material,8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO' I REPAIRIiNDOITION-I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available_within,20O.feet.l 1 ' <br /> installation will serve: Residence=,. Commercial ther NiT� _ - - �'-�---'- 1 <br /> Number of living units: Number of badrooms� <br /> Character of soil to a depth of 3 feet: 1� Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity�� No. Compartments <br /> ;.: I <br /> PKG. TREATMENT PLT. ❑ , , ; ° Method of Dispos it <br /> Distance to nearest: Wellj0W/->iFcundation Property Line J' <br /> W1 <br /> LEACHING LINE ❑ No. & Length of linesof 1 length/size y= <br /> FILTER BED 1 ° ❑ Distance to nearest: Wefl FoundationProperty Line <br /> SEEPAGE PITS 11 Depth.j- Sire N mbar 20 <br /> } f <br /> SUMPS LI Distance to nearest: Well Foundation Property 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 <br /> rules and regulations of the San Joaquin County y <br /> Home owner or licensed agent's signature certifies the following: "I certify tharin ttie—p—e-dofmance 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 of California." ; <br /> The applica mast call for uked inspections. Complete drawing on reverse side. F <br /> Signed X Title: 9 �.< � Date: <br /> E=_ <br /> OR MENT USE ONLY [ <br /> Application Accepted by ! Date �` L res <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Courity Public Health Services ��fq <br /> x Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2008, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUIJIT REMITTED CK H CEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH13-24 IREV. <br /> tl <br /> EH 14.25 <br />