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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 0 BOX 2009, STOCSTON, 'CA 95201 <br /> PERMIT EgPIRES 1 YEAR FROM DATE­ ISSUED <br /> .,(Complete .in Triplicate) <br /> Application Is hereby mads 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 $an <br /> Joaquin County Public Health Services. .l <br /> Job Address Lot Size/Acreage <br /> Owner's Name Address f � ' ' hone <br /> Contractor n- i � AddressV 4 License No. x / Phone / f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION_lt7ut of Service Well 0 <br /> PUMP INSTALLATION•❑- _ ,SYSTEM REPAIR ❑ OTHER.❑ Monitoring Well <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE ~ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t n industrial ❑ Open Bottom ❑ Manteca ".Dia. 0f,Well Excavation" ,_ Dia. of-Well-Casing <br /> Domestic/Private Cl Gravel Pack ❑ TracyType of Casing- Specifications' <br /> I I'I Public fa Other I Cl Delta - Depth of Grout Seal Type of Grout <br /> i 1 Irrigation Approx. Depth 1,1 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump I H.P. t State Work Doe _ <br /> Well Destruction Well Diameter SealingMaterial & Depth <br /> Depth -/ I Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 ) REPAIR/ADDITION I 1 DESTRUCTION i 1 (No septic system permitted iltpublic sewer is <br /> t - - t available within 200 feet.) 1,t <br /> Installation will serve: Residence Commercial'_ Other t - r <br /> Number of living.unita: Number of bedrooms <br /> Character of soil to a depth of 3 feet: f MOW. " <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg j f Capacity No. Compartments <br /> PKG. TREATMENT PLT. C1 <br /> { �,r Method of Disposal I <br /> ' Distance to nearest: We[(. Foundation �'"�'Property Line f <br /> LEACHING LINE L) No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation " "'r NA =Property Line <br /> r SEEPAGE PITS 11 Depth 1 'Size } Number 1' "t", <br /> r SUMPS L7 Distance to nearest:"` Well Foundation 1 i <br /> ` Property`Line I <br />-j.( DISPOSAL PONDS ❑ t�k � f, � r �{ � """ `� � t <br /> I hereby certify that I have prepared this applications and that the work will be done in accordance withrSan Joaquin county ordinances, state laws, and <br /> rules and regulations of the'San Joaquin County <br /> Home owner or licensed agettit s signature certifies the following: "t certify that in the performance of,`the work for?which this pfermit:is issued, I shall not C t <br /> employ any person in such manner is to become subject to workman's compensation laws of California." Contractor's hiring,orisub-contracting signature <br /> *� certifies the following: "1 certify that in the pertormarice of the work for which this permit is issued, I shall employ persons subject;to workman's compensa- <br /> tion` ;tion laws of California." s _ c J <br /> 'The appticaust & I requ, tionsComplete drawing on rev side. <br /> t � <br /> Signed t ride: , <br /> Date: <br /> � 1 FOR pEPA'RTf1AENT USE ONLY � I <br /> Application Accepted by i 'g_f, <br /> ' :Date �� �. Area <br /> Pit or Grout Inspection by ! {Date = Final Inspactionfby Date <br /> # 1 <br /> )Additional Comments: -75" Wa4f v-1 4A { . f Jf r <br /> - -APp13-cant Return-al-l- eo ies-�to••-� � q� � y� <br /> p San Joa uin-Count -i>ub1lcHea1'th Se' Ce"s°"-"" D' �^-� � �T ��.•. -moi <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMONT14MITEj,�INFO C <br /> / RECEIVED BYJD <br /> ATE PERMIT'NO, rr!! <br /> . EH17-211REV"L/mw <br /> EH t4•26 — , <br />