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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 msde to Sa '' oaquin Gounty ,for a permit to construct and/or install the work herein described. This <br /> application is made.in co®pliance`W'Ith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> 'Joaquin County Public Health Serv+ftes. <br /> City Lot Size/Acreage <br /> Job Address t <br /> Owner's Name Address Phone / <br /> Contractor Address tf40S " License No. Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. CI Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ 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 /> F] Industrial ❑ Open ttom f❑ Ma a Dia. of Wall Excavation_ Dia. of Well Casing <br /> [1 Domestic/Private ravel Pack f racy Type of Casing_. Specifications <br /> I'I Pub' fa Other [7 Delta Depth of Grout Seal Type of Grout <br /> 1 rigation•-,:,,. _ Approx. Depth Eastern 5u e SeuI Installed by <br /> Repair Work Done Type of Pump H-P• State Work Done <br /> Sealing Material 8 Depth <br /> Well Destruction ❑ Well Diameter. �� <br /> Depth Filler Materiel & Depth / �1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAODtTION I I DESTRUCTION l 1 (No septic system permitted if public sewer is Q <br /> available within 200 feet.l (� <br /> Installation will serve: Residence Commercial_ Other (� <br /> T <br /> Number of living units: Number of bedrooms PAYM <br /> Character of sail to a depth of 3 feet: Wit _P <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. <br /> r'(mp�rt gr' <br /> PKG. TREATMENT PLT.❑ M o i o ai <br /> Distance to nearest: Well Foundation Propetgy,14in_OM `jN COy, r, FS <br /> se; Ir HF-AL-11 �C; I <br /> LEACHING LINE ❑I No. & Length of lines Total IerTd1ft1h@C1NMEN1 A <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth j Size Number <br /> SUMPS LI 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 <br /> Home owner ar li nsed agent's sJoaquin County ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any per o in such manner as.to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fol Ing:Aceha,in4he pert mance of the work for which this permit is issued, l shall employ persona subject to workman's compensa- <br /> tion Iowa of i rnia <br /> The appl' a st ca ,a ns. Complete drawing on r Yside. <br /> Signed X Title: Date: L <br /> FOR DEPARTMENT USE ONLY/fix � <br /> t Application Accepted by Area Date <br /> II <br /> Pit or Grout Inspection by Date Final Inspection by Date 7 4� <br /> Additional Comments: f <br /> f <br /> Applicant —Return all copies to: San Joaquin County Public Health Services <br /> Ettvironmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REIMtTTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO J � e� <br /> . EH 13.241"EV.riat5i !► "l S_ fT LS �L77) -� L-} 7 <br />