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SAN JOAQUIN COUNTY\PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 S E P 1 7 1992 <br /> P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID � � vk� <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 1 <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. <br /> Job Address <br /> 0I AIL. d City G M AD Lot Size/Acreage <br /> Owner's Name IL Fi$ G19le K1 N1 Address �� Phone ZO - Z <br /> q5'2,: 0 <br /> N �/. Address + 0 0 X 117-1 3 -C-K31Kicense No. 6 3 S <br /> Contractor �2 Phone �� <br /> TYPE OF WELL/PUMP: NEW WELL (3 WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ <br /> OTHER Monitoring Well Ll <br /> PUMP INSTALLATION C) SYSTEM REPAIR ❑ SV 4L 8 alu'Ni.i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 S'D-Ya n DISPOSAL FLD,L�20*PRt LINE 10 v <br /> FOUNDATION . SD AGRICULTURE WELL 4100 ' OTHER WELL 0 0 PITS/SUMPS -- - - " <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> H Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications <br /> I'1 Public IV Other $a 1 I Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction X Well Diameter Sealing Material & Depth � <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic systithinem <br /> rented if public sewer is <br /> avaInstallation will serve: Residence— Commercial _ Other <br /> " 4 <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. 7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> f SUMPS 0 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 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 laws of California." <br /> The applicant must cal 191 all required inspections. Complete drawing on reverse side. <br /> Title: e.P-4-P-4- Date: <br /> .Signed �- <br /> ` FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by at <br /> Fine nspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 1 �® OV <br /> Health Permit/Services Q['] <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 / f� <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. (� <br /> INFO <br /> . FH 13-24[REV,"5) <br /> EH 142E <br />