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'r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTALHEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i <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. j � <br /> Q A <br /> i _ ) City 7 341 Lot 'Size/Acreage <br /> Job Address <br /> r+ { Phone <br /> Owner's Name !C C/h i�,l)� -tw — Address <br /> '4,50 c2� tip" ��yy'� X817 <br /> Contractor �[R� Address <br /> License No.M. S+ 4S Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Servic7wellO <br /> TYPE OF WELLIPUMP: OTHER ❑ Mopitorin <br /> PUMP INSTALLATION SYSTEM REPAIR C7 <br /> SEWER LINES � DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK — PITS/SUMPS <br /> FOUNDATION —_--- AGRICULTURE WELL OTHER WELL <br /> I{ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Weil Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> I [} Industrial Specifications <br /> Type of Casing <br /> [?Domestic/Private ❑ Gravel Pack ❑.Tracy Qepth of Grout Seal Type of Grout <br /> I'i Public (:1 Other {[' f fl Delta <br /> _Approx,'Depth t I Eastern Sudan Seal Installed by � <br /> I Irrigation , .* State Work Done <br /> Repair Work Done LJ Type Te of Pump �CL�. H.P. —�— � <br /> Sealing Material& Depth �� <br /> Well Destruction `o Well Diameter Filler Material & Depth <br /> Depth f: <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIfllADDtTION { I DESTflUCTiON l I availableiwthine200 feet.) if public sewer is <br /> y � <br /> Installation will server Residence Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: _ -- -.—No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity ^-- <br /> Method of Disposal <br /> i PKG. TREATMENT PLT. ❑ Property Line <br /> E{ Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTEfi BED ❑ Distance to nearest: Well Foundation , <br /> SEEPAGE PITS I I Depth Size <br /> _.,_ Number � <br /> SUMPS CI Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS D t <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, an ` <br /> r 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, k shall not <br /> employ any person in-such manner as�to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: "s certify 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 California." <br /> The applicant mus for all required inspections. Com to drawing on ray a aid rG <br /> Title: <br /> f/ Date: —7= 7 _ <br /> Signed X <br /> FO DEPARTMENT USE ONLY <br /> Date —7 Z_ Ar a <br /> r Application Accepted by —4 <br /> Data Final Inspection by Date I <br /> Pit or Grout Inspection by y - 10 <br /> Additional Comments: I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> w 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> i FEE AMOUNT DUE AMOUNT REMITTEE <br /> RECEIVED <br /> CK BY DATE PERMIT NO. <br /> ' INFO <br /> . EH 13-741 iREV.r K 51 [_. f <br /> 444 EH 14"0 1 <br />