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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Y 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 /> (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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address n A NA19" &AJ2 City 9*Ck9W Lot Size/Acreage <br /> Owner's Name Awk J&sg2 Address PJ2 gog go 2Z -1r&CkA*AJ___ Phone <br /> Contractor « Address Ad.!S62L ;?WG ClOk License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL JC WELL REPLACEMENT R DESTRUCTION o Out of Service Well Cl <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER 0 Monitoring Well C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> estic/Private 0 Gravel Pack O Tracy Type of Casing_ Specifications <br /> i"1 iblic 1-1 Other (l 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 Pum H.P. State Work Done_ <br /> Well Destruction O Well Diameter Scaling Material i Depth <br /> Depth ds a Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is ' <br /> available within 200 feet.) <br /> Installation will serve: Residence Af— Commercial_ Other , <br /> Number of living units: _/ Number of,. AUN bedrooms <br /> ,� — <br /> Character of soil to a depth of 3 feet: � 4,,&Aaa Water table depth <br /> SEPTIC TANK O Type/Mfg P r L Capacity/6 0 Got No. Compartments <br /> PKG. TREATMENT PLT.0 .0 Method of Disposal <br /> Distance to nearest: Well 1d0 f- Foundation 90 Property Line /0 f <br /> LEACHING LINE Cl No. & Length of lines {� - -- Total length/size <br /> FILTER BED CI Distance to nearest: Well 100 Foundation �.�r Property Line 1Q <br /> SEEPAGE PITS 11 Depth �,$ SizeNumber <br /> SUMPS LI Distance to nearest: Well _ Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 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 r <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 mu calf for all ed ins , tions. Complete drawing on reverse side. - <br /> Signed X ��.�/�✓Z:�Y�fi� Title: thew,., ezezg -- Date: Jam( <br /> ARTMENT USE ONLY <br /> Application Accepted by 6L k_- � M <br /> C Date L Area <br /> Pit or Grout Inspection by Date Final Inspection by Pff Date <br /> Additional Comments: a- <br /> Applicant - Return all copies to: San Joaquiq County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO ) <br /> . EH 1211REV.Iinsi CJ- <br /> EH 14.4Ie ry ( 1 1 J <br />