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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 I YEAR FROM DATE ISSUED � � J /�, <br /> (Complete in Triplicate) we'll <br /> � i �E' <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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> - n k cf-C_ <br /> Job Address�an�° �-�'aa4 1 -7-0:K: `�0.� A��' ty�-��PCity ��^a��� t Size/Acreage <br /> Owner's Name ) �• a R A plf'�_apl`( hbd"r ss 1 C!2!2 m Ll R 1 Phone LSPs2l <br /> Contractor fNil 11 N el Address �- License Waclg3 s Phone 7 <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL � T DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK n O�r SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT,IS�/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCATI NS W01 �- <br /> F_1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Oia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ � Ea✓ Specifications <br /> I'1 Public 1.1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation ____.Approx. DjWTn t I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. Z�E—,n State Work Done p <br /> Well Destruction D Well Diameter Sealing Material b Depth J3 <br /> Depth Filler Material ii, 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 <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line T' <br /> SEEPAGE PITS 11 Depth Size Number <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, andr--� <br /> rules and regulations of the San Joaquin County V <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 or sub-contracting signature <br /> certifies the following: "I 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 taws of California." <br /> The applicant must callforall requirep inspections. Complete drawing on reverse side. <br /> Signe � a o t ( 4a AAnA_AeN1,_. Title: S ete-4�2e S Date: <br /> OR itARTMENT USE ONLY q <br /> Application Accepted by Date 7: L Ar <br /> Pit or Grout Inspection by Date Final Inspection b Date <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 <br /> INFO� AMOUNT DUE AMOUNT REMITTED CK I rCgAa5H RECEIVEDBY <br /> �7 DATE q) PERMIT'NO. <br /> . EH13-24IREV.I/"5i W *0 d 1 ri 1a Q~ ` •V <br /> EH 1426 v f / � � / <br /> �� `'t,OD <br />