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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 made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in oompliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations. of San <br /> Joaquin County Public Health Services. <br /> Job Address 14088 E Ke t C 1 P an Ln . _._ City Lot Size/Acreage <br /> Owner's Name AR UES Address 14088 E e IL Ln . Phone <br /> P .O. Box 113 <br /> contractor Goehring Pump Address LockefOrd , CA License No, 309031 Phone 727-5548 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIW2 OTHER 0 Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> — INTENDED-USE"—­­TYPE TYPE OF—:WELL---—PROBifM-AREA---=CONST-RUCT40N=SPEC,*FICA-7IONS* = <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 177 Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> FI Public 17 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx, Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump Sub- H,P. 3 State Work Done zPp 1 aced old pump <br /> Well Destruction ❑ Well Diameter Seali"ng Material A Depth <br /> Depth "Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I 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 f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Co�� <br /> PKG. TREATMENT PLT.L1Method`ot90 <br /> Distance to nearest: Well Foundation Property LineREZEIVE <br /> ! 2 41992 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size �J,I - <br /> FILTER BED s ❑ Distance to nearest: Welt Foundation Prope S JOAQUIN COUNTY <br /> r�CJ ' C �H ERV10ES <br /> SEEPAGE PITS it Depth Size Number <br /> SUMPS Ll 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, I shall not <br /> employ any person in st4 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followin ertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compertsa- <br /> tion laws of Calif <br /> The applicant for required inspections. Complete drawing on reverse side. <br /> Signed X Title: Bkp r . Date: _07Z22/92 <br /> FOR DEPARTMENT USE ONLY ,� <br /> Application Accepted by A-4w 4A <br /> Date 7- �Z a JN' <br /> Pit or Grout Inspection by Date Final Inspection by Oata�ir i <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INfO CASH <br /> RECEIVED BY GATE PERMIT N0. <br /> EHt7.21(REV.s�x51 4f7�/ YCL, <br /> `� <br /> EH t4-2s. !ir <br />