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e <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> s ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN J'OAQUIN, PHONE (209)468-3420 � <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> 'f <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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. , L! �r <br /> �.5l r Jl'rFa City I y Lot Size/Acreage <br /> Job Address <br /> .. Address J� �GRSf (_f ' S_ re Phone 3a - 0?$5 <br /> Owner's Name _{ <br /> 5na . Address 10 M- +tom License No. 9 Phone 1855-350 <br /> Contractorell f Service <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION Out Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom [I Manteca Dia. of Well Excavation — <br /> Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack ATracy <br /> Type of Casing_ Specifications <br /> IlPublic <br /> I:1 Other 171 Delta Depth of Grout Seal Type of Grout (� <br /> 11 Irrigation —.Approx, Depth I I Eastern Surface Seal Installed by <br /> H. State Work Doe <br /> Repair Work Done C] Type of Pump <br /> h Sealing Meter &I & Depth <br /> Well Destruction 9 Well Diameter <br /> Depth �9 +- Filler Matirie.1 & Depth <br /> TYPE OF SE TIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I}1 DESTRUCTION l I (No septic system permitted if public sewer is ! <br /> available within 200 feet.I <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 ❑ TypelMfg Capacity No. Compartments <br /> 4 Method of Disposal 4 <br /> PKG. TREATMENT PLT. ❑ _ e <br /> --Distance to nearest: Well Foundation Property Line �_ I <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> Num <br /> SEEPAGE PITS 11 Depth Size Number <br /> , <br /> SUMPSn A LI Distance to nearest: Well Foundation Property Line Y �; <br /> DISPOSAL PCa ► ❑ <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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu call IN all required pections. C mpl to rawing on reverse side. <br /> Signed ` Title: 4• SO Date: S I <br /> ���] // r7 ❑ FOR DEPARTMENT USE ONLY y <br /> JdC'.A_AY.i l ]r 7/ Area <br /> Application Accepted by r�- _— Date Z <br /> Dae Final Inspection by_ ""�- Date <br /> Pit or Grout Inspection by <br /> F Q A <br /> Additional Comments: <br /> Applicant - Return all opies to: San Joaquin County Public Health rvices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 _( <br /> FEEEtOUMNT DUE AMOUNT REMITTED CASFI RECEIVED BY DATE PERMITNO. <br /> INFO ,.,� J <br /> . EH 13-14IliEV.l/Rsr � co <br /> X33 ��`� �D Z R� <br />+t EH 74.28 <br />