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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 0 BOX 2 Ol STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <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 ccupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Service. <br /> Joh Address � <br /> ( ' .zUIJ AO-Ily <br /> _ Cit Size/Acrea.ge <br /> - <br /> -rarillJbwf6j Ny I <br /> I � <br /> Owner's Name .Z <br /> Address ;al i Phone <br /> Contractor Address �_ Lqll_ License Not 23 Phone <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION WOut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well CZ <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION L 4AGRIWCTURE WELL " ' "' OTHER WELL "_ � �_= PITS/SUMPS — <br /> INTENDEO USE, TYPE OF WELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f1 lnduftrial , _-_*' ID Open Bottom: ! ❑ Manteca Dia. of Well Excavation Dia. of Well`Casing' <br /> [a-0660'siic/P­FrivMe —L)'Gravel Pack ❑ Tracy Type of Casing_ Specit.irations <br /> I'I Public C1 Other 1 n Delta Depth of Grout Seal '' Tpe of'G'rout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done 0 Type of Pump Ir H.P. State Worc Done <br /> Well Destruction Well Diameter Sealing Material & Depth < <br /> �.+ <br /> Depth_ ^�SJ Filler Material-d._Depth- M <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIADOITION I C DESTRUCTION I I fNo septic system permitted if public sewer ismer <br /> available within 200 ftiet.l <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/Mfgi l �Ca tty` �lo. Compartrnents x <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> I <br /> Distance to-nearest: II undation ProperW,,,,Line - <br /> ! s <br /> LEACHING LINE ❑ No. & Lengtl of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ji <br /> SEEPAGE PITS 11 Depth ' S' a Number <br /> SUMPS LI Distance to nearest: all Foundatio Property Line <br /> DISPOSAL PONDS ❑ 1{ <br /> I hereby cenify 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 regula ' o an Joaquin C6dnty <br /> Homs owner licensed agen signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ an rson in such ma or as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature- <br /> certifies t following: "I cavi that in the rforma s the work for which this permit is issued, I shall employ persons subject to workman's compensa= <br /> tion law of Califor Ia." <br /> The ap icant all req red omp to drawing o (se <br /> Dale: <br /> Signed X Title: yl <br /> k <br /> _4 <br /> Fnr+, DEPARTMENT USE 011fLY <br /> Application Accepted by !/ 4 Date_ - _._ Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> tP" <br /> alk, cwkm4 <br /> w <br /> Additional Comments: or 1 11 a '��� 5' � o <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ++ II <br /> Environmental Health Permit/Services � qr <br /> 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 t <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PEAMI'f N0. <br /> INFO CASH ��+7 <br /> EN 13.241 REV.IiH5) W d��� j ! ✓•q� q3 <br /> EH 14.25 rr <br />