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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$--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 trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in Compliance with Ban Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address +�r��`q�d� `f;7 7 S- City ArWAL6 Lot Size/Acreage <br /> Owner's Name Or m Jit Address L_3_� 1 +` —la' Phone <br /> Canttactar Address Ofl �.rJYV License NoPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 71 OTHER p 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 /> ❑ Industrial ❑ 0 Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [:1 <br /> Domestic/Private W6ravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I �­c <br /> I-1 Other [l pelta Depth of Grout Seal Type of Grout <br /> I on -Approx. Depth I Eastern Surfs a Seal Installed by <br /> Repair Work pone U Type of Pump I H.P. rtState Work pone _J4 m , <br /> Well Destruction ❑ Welt Diameter Sealing Material ds Depth <br /> Depth^ .J Filler Material A Depth �Al <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.I �I <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 table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � Me 0' <br /> Distance to nearest: Well Foundation Property L �W�TT+ 'Ilii''C�llr�:.�ltltl <br /> EIVED <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> AUG ic-19-2- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> �N7Y <br /> SAN J� <br /> SEEPAGE PITS 11 Depth Size NumbeF,. f IViS'U <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 Joaquin County <br /> Home owner or lic need 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 per in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> eertifies the fol ng: "I certify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C .0 rale." i <br /> The applica ust call r quire Complete drawingon ev a si p <br /> Signed Title: Date: <br /> .FOR DEPARTMENT USE ONLY ti <br /> Application Accpled by -)Date 4L' Area �C7 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ylce u 1,14cs-AZug ea <br /> Applicant - Return all copies to: San Joaquin County Public Health Services C« <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEEs <br /> INFO AMOUNT DUE AMOUNT REMITTED rrCAK . RECEIVED BY DATE PERMIT NO. <br /> • EM 13.24IREV.1/x51 P� T � 0-01&2 <br /> EH 11.20 7 <br />