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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> f 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS-SUED <br /> i (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 Rules and Regulations of San <br /> Joaquin County Public Health Services. ,,,/ 7� <br /> LJobAddress <br /> Sr � a �I���� �I�JsY � City�� Lot Siae/Acreage <br /> �r If <br /> ?melAddressPhone ✓a y1,� License No. Phone"4r'r, 4O Address <br /> ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> / Monitoring Well L3 <br /> PUMP INSTALLATION .- SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C7 <br /> I Industrial LlOpan Bottom ❑ Manteca Dia- of Weil Excavation <br /> Type of Casing Specifications <br /> ra:Domesticl Private ❑ Gravel Pack L1 Tracy Type of Grout <br /> I'll.?ublic #1 Other n Delta Depth of Grout Seal <br /> i I tr6ation .f pprox. Depth l I Eastern Surface Soul Installed by J <br /> Repair Work Done 0 Type.of Pump <br /> State Work Done <br /> H.P. _ <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material& Depth <br /> ;T Depth. - .: +-. <br /> TYPE OF SEPTiC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I 4 DESTRUCTION l I (No septic system permitted if public sewer is <br /> II available within 200 feet) <br /> i Installation will serve: Beside nce S:- ;�.Goihmefcial Other - <br /> fNumber of living units: { Number of bedrooms <br /> f Water table depth <br /> I Character of soil to a depth of 3 feet: <br /> r <br /> l Capacity N <br /> SEPTIC TANK D °yType/Mfgo. Compartments <br /> PKG. TREATMENT PLT. ❑ i; I� Method of Disposal <br /> r- Distance to nearest: Well Foundation Property Line <br /> LE C ING LINE Cl NIo. & Length of lines - 7 I Total length/size <br /> FILTER BED D istance to neaiest:; Welt Foundation l Property Line 41's <br /> ;pie NumberI ; <br /> SEEPAGE PITS <br /> SUMPS Pro Line <br /> L! Distance to nearest: Wall Foundation Property <br /> f DISPOSAL PONOS ❑ III <br /> k <br /> I hereby`certity that I have prepared this application and that the worts will be done in accordance with San Joaquin county ordinances, state laws, an <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,woilk for which this permit is issued, I shall not <br /> employ any person i such mariner as to become subject to workman's compensation;laws`-of�Cslilornia�"aCoritractarls hiring or sub contracting signature <br /> cartil.0, the folio : "1 certify�that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa <br /> tion`I`ews of C nla." <br /> The applica ust all fo t I� uired inspection . Complete drawing on reverse side, pt Z <br /> Signed y <br /> Title: -�o �`"� - Date: <br /> FOR EPARTMENT USE ONLY u <br /> Date `� dl`O- 1�._ Area r <br /> I 2. <br /> Applkaiigri Accepted by <br /> j -Pit ar Grout inspection by <br /> Date Final Inspection by Data 2, <br /> I Additional Comments: <br /> iM. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> k 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RCK XECEIVED BY PATE PERMiT'NO, <br /> INFO <br /> . EH 13.24 IREV.I/w 5 <br /> EH 14.25 ' <br />