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r � <br /> t -tea <br /> t 1 <br /> 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 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 /> 3 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 0- f City d haj I,ot Size/Acreage <br /> n - <br /> Owner's Narne(2A� dress -rM4P Phone <br /> Contractor eU.01VAddress �126 11 13. License No d v Phone <br /> TYPE OF .WELL/PUMP: - NEW'WELL.0., .� WELL REPLACEMENT Cl l DESTRUCTION Out of Service-weli•-_❑ .-.-- <br /> 1 1 PUMP INSTALLATION D SYSTEM REPAIfi'C7` "" i` ­�UT�IiR p F Monitoring 11e1i` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. � PROP. LINE <br /> 4 ; FOUNDATION AGRICULTURE WELL OTHER WELL �' PITS/SUMPS <br /> INTENQED.USE / TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial- ��'� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />' F} DomesticPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'i Public Y�, r El Other n Delta Depth of Grout Seal Type of Grout <br /> t <br /> I I Irrigation..-. Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair;Work Done Q Type of Pump H.P. State Work Done _ <br /> Well Destruction, 0 Well Diameter Sealing Material <br /> 7, Depth & Depth a <br /> �' Filler Material & Depth ° <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I k DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 !set:) <br /> Installation will serve: Residence_ Commercial T Other <br /> j i <br /> Number'of living units: ` .Number of bedrooms ^' <br /> Character of soil to a depth.of 31eet:'t '' s 'J, I - i�s' j, ' t Water table depth <br /> SEPTIC TANK. D Type/MigCapacity No. Compartments: ' <br /> PKG. TREATMENT PLT.❑ . r ! / `S .,tr � Method of Disposal t 6 <br /> Distancd'to-Ttearest:- Well. .Foundation _ _Propeyty Line,. <br /> LEACHING:LINE ❑ No. 6 Length of tines ?Total iength/size <br /> FILTER BED n Distance to nearest: Well Foundation; ' Property Line <br /> SEEPAGE PITS 11 Depth Size ` �f Number +x; <br />' SUMPS Ll Distance to nearest: Well Foundation Property Line 4 <br /> - k <br /> DISPOSAL PONDS 0 <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 /> i rules and regulations of the San Joaquin County 'f <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 workinan's compensation laws of California." Contractor's hiring or:sub-contracting signature <br /> certifies the following: "I certify that in the performance of the daoyk for which this permii!is'issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu all fo equi inspections. Complete &awing on reverse si t <br /> iSigned Title: _� -- Dale <br /> i �? f M1 s <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by�i ` I Date s __ Area U <br />€` Pit or Grout Inspection by Date Final Inspection by Dated <br /> f Additional Comments: <br /> r i , <br /> Applicant. - Return all copies to: San Joaquin County Public Health Services k j <br /> Environmental Health Permit/Services ! <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 1; 1 <br /> f _ <br /> IFEO AMOUNT DUE AMJO{{UNT REMITTED �K RECEIVED 13Y D TE � PERMIT'NO. ; <br /> . EH 13-24(REV.1/K51 LYO •� V ! ' - I q� <br /> EH 1420 <br /> lIF <br /> i <br /> t <br /> 1 a <br />