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SAN JU <br /> IN COUNTY PUBLIC HEALTH <br /> HEALTH DIVIS <br /> 445 N SAN JOAQUIN, PHONE (209)44�0 <br /> P 0 BOX 2009, STOCKTON, CA 9 <br /> PERMIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <br /> A;;'.fcstton Is hereby made to San Joaquin County for a permit to construct and/or <br /> lj�plication is made in compliance with San Joaquin County Ordinance No. 549 and 16152 <br /> ,'uaquin County Public Health Services. <br /> bAddross IF ,� c �/ —__ City . It�(� _ Lot Size/Acreage <br /> 'lwner's Name —~?�Wg'j'�/ f(_ Address t / lY Phone J� 'y42 <br /> Contractor-.6"21 - 1- Address - Y ' �1 �._!/, ir 'l�/G — Licenser NoYTT Phone;./ 15.__. <br /> TYPE-OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT F1 DESTRUCTION PoNut of Service Well C.l <br /> PUMP INSTALLATION U SYSTEM REPAIR U 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 W�u— # 3 <br /> 7--.__...__ <br /> ,,mdusvral O 00 n Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private C GraveI Pack O Tracy Type of Casing_ — Specifications-- •• <br /> PUbliC f_1 Other (1 Delta Depth of Grout Seal Type of Grout <br /> Irrigation ___ Approx. Depth ( I Eastern Surface Seal Installed by <br /> ���� <br /> Re;�ah U Work Done ype of Pump �='—i— H.P. State Work ne,* H <br /> Well Destruction Well Diameter � Sealing Material & Depth � <br /> Depth , �7 Filler Material & Depth _ <br /> I YPE OF SEPTIC WW-,::: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCPD �y ptic system permitted if public sewer is <br /> VAft'j s'�i6ithin 200 feet.) (� <br /> Installation will serve: Residence—_ Commercial .—__ Other �I 1� <br /> Number o9 living units: Number of bedrooms EIld�;C) <br /> DECC � p <br /> Character of sU <br /> oil to a depth of 3 feet: _ _ C C � or table depth <br /> iFPTIC TANK O Type/Mfg ------- -- ..__ CBPKj CC1t40q-nompartments — <br /> PKG. TREATMENT PLT. 0E rdViRONM ENTA( <br /> A H SFRUJWof Disposal <br /> Distance to nearest: Well _.-_ Foundation UiAhrQ ii wloPj <br /> LEACHING LINE Cl No. & Length of linea __— Total length/size _ <br /> FILTER BED 1-1 Distance to nearest: Well Foundation _!— Property Line <br /> SEEPAGE PITS 11 Depth —Size _ _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> n1SPOSAL PONDS 0 <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 /> ru es 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, 1 shall not <br /> employ any person i "such manner as to become,subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the follo in : "I certify,that in the pert jhance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> >ion laws of Calf la." / <br /> Tl,o appli ant u call for r, q Complete drawing on r eZs /s,,de. <br /> r71:igned X Title: i <br /> Date: <br /> FOR DEPARTMENT USE ONLY L <br /> Apribcetion Accepted Iby _ _ �/�(�.' - — Date ��r / Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <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 O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a-:I)�rlOFv.r,hs to <br /> 16401640 [�xy <br /> EH 14 20 �.7 1/001l'T(J <br />