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� � M <br /> j 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 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. ',,l <br /> lob Address �� ��r ` � �� City ��1� M Lot Size/Acreage <br /> y�Owner's Name i�/`�� 10 6�ddress ` � 3 ZZ <br /> .. Q' hone <br /> ontractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well C7 <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 /> n Industrial ❑ Open Bottom O Manteca Dia. of,Well Excavation Dia. of Well Casing <br /> I'] Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'l Public El Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I ],Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter - Sealing Material..& Depth' <br /> Depth Filler Material &.-Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms \ <br /> Character of soil to a depth of 3 feet: Water'tabls depth <br /> SEPTIC TANK ❑ Type/Mfg ^-Capacity _.No._Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total len th/size <br /> 9 g <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number , <br /> SUMPS CI Distance to nearest: Well Foundation 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 <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 in sucp manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies'the following: " ertify 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 Californl <br /> The appl' m call for all requir tions. Complete drawing on rr Jside. <br /> KSigned l�J_A` - .-%A—f Date: <br /> FOR DEPARTMENT USE ONLY q <br /> Application Accepted by i�. a1A� Date Area <br /> Pit or Grout Inspection by BDate Final Inspection by Date <br /> Additional Comments: R�`�z ! Li <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 AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT'N0, <br /> INFO CASH <br /> . EH12 (REV.tie51 6 a C 0n <br /> EH t4.1.2e Cl <br />