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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j� (Complete in Triplicate) <br /> far a permit to construct and/or 1 install the work herein <br /> Application is hereby made,to San Joaquin County described. s <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi'es. / fr <br /> �. r✓c-f}4 , /Q� a Lot Si ze/Acreage <br /> 6 0 7v ! cf /� Gity <br /> Job Address Phone <br /> "Address <br /> ����C l r'Owner'sName �' /�� <br /> � - <br /> �� ` Nl��OAddress rp' �r. License No. $ Phone <br /> Contractor.�- = � � DESTRUCTION ❑ Out of Service Well ❑ <br /> NEW WELL Cl WELL REPLACEMENT ❑ Monitoring Well Ll <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR 0 OTHER Q ; <br /> PUMP INSTALLATION O <br /> SEWER LINES _�— DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL PITSISUMPS <br /> OTHER WELL <br /> FOUNDATION: -- <br /> NDEU Ubt'�'� TYPE"OF WELL- PROBL_ �EAAAREA"^`CONSTRUCTION SPECIFICATIONS- Dia. of Well Casing <br /> Dia. of Well Excavation <br /> L-i industrial ❑ Open Bottom [I Manteca r t Specifications - <br /> ❑ Tracy Type of Casing <br /> Ca Domestic/Private C1 Gravel Pack r--s Depth of Graui 5eai � V Type of Grout <br /> i 1 Other fl Delta <br /> I'1 Public Surface Seat Installed by -� <br /> .Approx.-Depth lJ_Eastern-__- __.x �_� . Done" r... State Work Dnne - a <br /> of Pump �--�-�- H.P. -�---�-^--'� « <br /> Repair Work Done U Type Sealing Material & Depth <br /> Well Diameter r <br /> Well Destruction ❑ Filler Material i Depth <br /> Depthpermit'ed if optic-"sewer is <br /> TYPE OF SEPTIC WORK: W INSTALLATION l I REPAIRIADDITION 1 1 DESTRUCT <br /> E I availab septic <br /> 200 feet.l p <br /> L Commercial— Other <br /> Installation will serve: Residence r: O <br /> Number of living units: _ Number of bedrooms� - :r f r <br /> �o IgM t_ Water table depth <br /> Character of soil to a depth of 3 feet" SAN n,; 3 Capacity t'JQ I�INCompartments <br /> EPTI T ❑ Type/Mfg 1 ^tee Method of Disposal <br /> " PKC. TREATMENT PLT.0 k Property Line """�"� � <br /> Distance"to nearest: Well © Foundation - 1 i <br /> Notal length/size11 57 <br /> LEACHING LINE No. & Length of lines <br /> Foundation )0 f Property Line <br /> FILTER BED CI Distance to nearest: Well —s�— <br /> l <br /> .'1 a-� f 0 Number <br /> SEEPAGE PITS JI Depth Size r j 0 ` Property Line,'� _ --- �--'? <br /> Foundation <br /> SUMP L! Distance to nearest: Well h s <br /> I DISPOSAL PONDS Cl f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin'!c ' ordinances, state laws, and <br /> 1 rules and regulations of the San Joaquin County g' work <br /> f l not <br /> Home owner or licensed agent's signature certifies thheGol`o orkman'srtcoympensation Ithat in the awsoohCalifo9niahg Contractors lhving op sub cont acermit is tnglsignlaturre <br /> employ any person in such manner as to becomes subject <br /> certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall amploy'peraons subject to work'man's cnmpensa <br /> tion laws of California." f # <br /> The applicant mus all r al required inspections. Complete drawing on reverse side' { -i <br /> r Date: <br /> Title: <br /> l Signed . <br /> �FdR DEPAf1TMENT USE ONLY <br /> Date r Area a`L <br /> lication Accepted by i �� <br /> Date <br /> Data3�. Final Inspection by <br /> or Grout Inspection by-r4 <br /> Additional Comments: <br /> Joaquin County Public Health Services <br /> Applicant - Return all copies to: San <br /> Environmental tie alth Permit/Services <br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE' AMOUNT REMITTED C <br /> K RECEIVED BY OATE PERItiA1T"NO. � <br /> INFO <br /> . EH 13-24(REV,'/K S <br /> t EH 14.20 r <br />