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F <br /> 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 /> } <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 L31ervieps.' <br /> Job Address o fF, City Lot Size/Acreage <br /> os� E - � 3��'�- l� f3 - <br /> Owner's Name LAddress s Phone <br /> r r <br /> Contract r 0cl Address �a'7 License No. � -Z�°Phone . <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION n Out of Service Well 0 <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ 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— rTYPE OF VNEL3";�+•FPR09t'fMAR£A—CON STAUC710N-SPECIFICATION S <br /> f7 Industrial CJOpen Bottom ❑ Manteca D4. of Well Excavation _` _— Dia. of Well Casing <br /> .f F v •"► ? <br /> CI Domestic/Private ❑ Gravel Pack ([7-Tracyas r Type_of.Casing= Specifications �+ <br /> Il Public Cl Other F1 Delta Depth of Grout Seal Type of Grout <br /> I } Irrigation �,Approx..0e-, '-I 1 Eastern" Surface Seal Installed by ' <br /> Repair Work Done U Type of Pump H.P. State Work Dane _ / <br /> &,Depth �J� <br /> Well Destruction ❑ ,•Well Diameter Sealing Material:• <br /> Depth Filler Material & Depth*% <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> / o available within 200 feet,I <br /> Installation will serve: Residence 1 Commercial_ -Other <br /> Number of living units: ... Number of rooms <br /> turn- <br /> OQ <br /> Character of soil to a dept of 3 feet:' Water table depth <br /> SEPTIC TANK. ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.////O (f, ,. /1 oaf Method of Ditpsosal <br /> Distance to nearest: Well <br /> 6 4L Foundation Property Line <br /> .,t... 0 <br /> LEACHING LINE No.`& Length of linens' � 0 '- 79tal length/size <br /> FILTER BEd i_!" Distance to nearest:' Well Foundation Property Line Y <br /> SEEPAGE PITSDepth. — _Size - — Number <br /> SUMPS Lt Distance to,nearest: Well��} Foundation (0 t Property Line <br /> DISPOSAL PONDS ❑ <br /> I"hereby certify'thatl"have-prepaf�d,tKis applicatiofir aritl'ttiac^the workiiviN bejdone in-accordance with Sari-Joaquin-couriiy-ordinarices, state I' aws,a d <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "f certify-that in the performance of the work far which this permit is issued, I shall not <br /> "`employ an-y-'person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature y <br /> certifies the following: "i certify that in the pertotmance of the work for which this permit is issued, I shall employ Persons subject to workman's compensa- <br /> tion laws of California." e <br /> The applicant st call for qui d inspections. Complete drawing on reverse sie. <br /> Signed --4 Title: O Date: <br /> FOR DEPARTMENT USE ONLY c� <br /> Application Accepted by Date r �-�-Z - Area <br /> 6F-4 Grout Inspection by/' ate�L.�L- 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 /> FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED_ BY DATE PERMIT'NO. <br /> INFO <br /> l <br /> . EH 17.24(REV.1)115) V 1� �i� ��L <br /> EH 14-26 <br />