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I" `� SAN JOAQUIN• COU$TY. IPUd C,.IHEALTH SERVICES " <br /> /1 v ENV I RONMFNT.4L. HEALTH"IDIVISIM <br /> I "� „445 N• SAN. J6QUYN aPH�NE {209}468-3420 , <br /> O <br /> ]0. .0 "BOX "20-09; 'STOCKTON,.:'CA 95201 <br /> { <br /> PERMIT "'EXPIRES. 1 YEAR FROM "DATE ISSUED <br /> (COmp.lete in Tr"1 icate) " <br /> r made to San Joaquin County for a permit to construct and/or- install the vork•herein described., "This <br /> Application is ,hOre�� <br /> ` application is wade In Compliance xith San Joaquin County:0>dinance No. 51+9 and 1862 and'the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> / <br /> OF 9F <br /> Job Address41 <br /> City Lot Size/Acreage <br /> ! <br /> Phone <br /> VY <br /> 1 Owners Name <br /> " <br /> Contrattor A6dress1 f lricense No. >'hone' <br /> TYPE OF WELL/PUMP; NEVV WELL 0 WELL REPLACEMENT n DESTRUCTION Cl out of Service Well Ll <br /> PUMP INSTALLATION SYSTEMIWAIR 0 OTHER 0 Monitoring Well <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTU ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE. ARE CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial 0 Open Bottom 0 Mantec Dia. of Well Excavation _— Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack 0 Tr Type of Casing__ Specifications r <br /> I'1 Public i-1 Other { iDe]ta Depth of Grout Seal". Type of Grout 1 <br /> I.I Irrigation _Approx, Deihl I Eastern Surface Seal installed by <br /> Repair Work Done. U• Type of Pump ` H".P:" State.Woik°Done -- <br /> Wa11 Destruction © ' Well Diameter .• Sealing" rial 8 Depth' <br /> Depth Filler Material &'Depth . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I 1 iNo septic system permitted it public sower is <br /> available within 200 feetl <br /> Installation will serve: Residence Commercial <br /> Number of living units: Number"ol bedroo of. ,rpr <br /> - <br /> Character of soil to edepth of 3 feet: r . ater table depth" <br /> SEPTIC TANK 0 Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 1 Method of Disposal <br /> 4• <br /> Distance to nearest: Well , Foundaion Property Line <br /> { LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED LI Distance to nearest: Well / oundation Pro Line ' <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS is�pce�nleslf �N�lfr <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 /> }come owner or licensed agent's signature cenifies the following: "I Canity that in the periormance 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 st call for all required inspections. Complete".Awing on reverse side. <br /> Signed X �! Title:' Dater �- <br /> f " <br /> t FOR DENAR ,( 15 NLY <br /> 1 � � <br /> i Application Accepted by at Area � <br /> g Pit or Grout Inspection by Date Final Inspection by Dats-�, a2 <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Pubs;/n Health Services <br /> ' Environmental Health Permit/Services <br /> 445 N San Joaquin, P,0 Box 2009, Stkn, CA 95201" <br /> INE@ AfiA0UN7 DUE AMOUNT REMITTED CK A CAST{ RECEIVED By DATE PERMIT'NO.. <br /> EM13-24[REV. YD <br /> £w 14-2e <br />