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•--1111 <br /> SAN *QUIN COUNTY PUBLIC HEALTH <br /> VIRONMENTAL HEALTH DIVISI VICES 00 <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 V pit <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 1862 and the Rut"ARd 0*M2,. of San <br /> Joaquin County Public Health Services. <br /> Job <br /> Job Address =143 G. r Clac1 _Ave— City R;0)01) Lot Si�c(,q � 21 <br /> Owner's Name -1 r C-O. Address P� A /1536�IVVPhonI <br /> Contractor'Ar i A ( Address ZC0 f �i �e No.5 3q 44 (TG'7 -7 03, <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT F1 DESTRUCTION t<Out of Service We11 <br /> PUMP INSTALLATION O 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 /> fl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_, Specifications <br /> I'1 Public 1-1 Other Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by_ f <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ C ) <br /> Well Destruction Well Diameter A I►1CSealing Material i Depth <br /> Depth (8 C) Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> INC�n <br /> Installation will serve: Residence_ Commercial _ Other available within 200 feet.PAYME <br /> RECEIVED <br /> !�LJ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartrp R J <br /> PKG. TREATMENT PLT. U Method of ?jMt' <br /> Distance to nearest: Well Foundation Properly Line c^�gNTAL HEALTH DIVISI N <br /> LEACHING LINE Cl No. 6 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 workmen'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 applicant ,must call for all required innssPections. Complete drawing on reverse side. f //�7 (� <br /> Signed x��%r �!?� �/iS/t Title: �iPn LQSrI�r` Date: ( C / l Z <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date 3-)L`A Z Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. <br /> EH t3 24(REV.1 5) vvY 0 r O� /� /y� Q <br /> EH 114.26 f a / I 33 <br />