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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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County (Public Health Services /�j� i <br /> Job Address v ` �a d / City Lot Size/Acreage A-- <br /> Owner's <br /> Owner's Name�a rr A -c-0O2A-- Address Same a S te�life 0- Phone • ' <br /> Contractor B 1 ra f'1 1/179 Address `')71 L_tt*A* License No. 3�� Phone A3 `� <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service Well <br /> " 1PUMP`INSTALLATION SYSTEM REPAI_R 0 'OTHER._0 . Monitoring Well L3 1 <br /> DISTANCE TO-'NEAR ---�--�-'--"-"--SEWE R-LINES--�--- - DISPOSAL-FLD.-�--PROP­L•INE----•--� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> _IN7,ENDE.p_U_SE._ TYPE,OF WELL__ PROBLE <br /> __ M_AR_EA_ CONSTRUCTION SPECIFICATfONS ` _L I <br /> Cl Industrial O Open Bottom w0 Manteca" , yGiA. of Well Excavation 'Dia. of�Wefl Casing�� = ' <br /> E"1 Domastic/Private , 0 Gravel Pack L7 Tracy Type of Casing- ' Specifications <br /> <f'l Public \ 1-1 Other, ` n Delta Depth of Grout Seal Type of Grout <br /> }I I'Irgation �Appiox. Depth l I Eastern Surface Seal Installed by 4j <br /> Repair Work Done Type of Pump , u6• H.P. State Work Done ,S ; �y ' } ' ' <br /> f Sealing Material & Depth ' <br /> 'Well Destruction 0 Well Diameter e <br /> Depth Filler Material.B,Depth <br /> i f v <br /> ;TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION 1 I\DESTRUCTION I I INo septic system.parmitted if public sewer is <br /> i [ available.within 200 feet.) F <br /> installation will serve: Residence_ Commercial,_.r.. Other <br /> jE Number of living units: Number of bedrooms <br /> sCharacter of soil to s depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG.1TREATMENT PLT. 0 MI �Ftli �Y <br /> } Distance to nearest: Well Foundation PropertIM <br /> LEACHING LINE * C1 No, & Length-of lines Total length/si - i <br /> FILTER BED n Distance to nearest: Well ` Foundation Prr@ ,JL" iJ NTY I <br /> PIJULIC HEALTH SER ICF.S <br /> SEEPAGE PITS 11 Depth Size y• Num4j4 lRONMENTAL HEAL iH UIVI`JF)r4 <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> i <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared tfiis�pplication and that the work wit! 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 such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following° "I certify that in the performance of the work for which this peimit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m sitii:� <br /> equire 'nspe, tions. Complete drawing on reverse si e. Il <br /> 1 <br /> c D !' Date:SignedTitle: - - - <br /> FO I EPA EN ONLY ® I <br /> Application Accepted by Date <br /> 'er Ar �/ d <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> .21 <br /> Additional Comments: j <br /> _Appl-1cant«—Return-all-copies-to:- San-Joaquin-County-Public"Nealth'Services <br /> Environmental Health Permit/Services, <br /> 445 N San Joaquin, P 0 Box 2009, Stk , CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EH13-241AEV.ri9 s) ��/. 114ri� J3d ! <br /> EH 14.26 <br />