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r_ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` <br /> ENVIRONMENTAL HEALTH DIVISIONA. <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 CIF � } <br /> P 0 BOX 2009, STOCKTON, CA 95201 a9 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED €�tS4P,i�0AQtj1N C�tlN, i <br /> (Complete in Triplicate) <br /> bert11� �? <br /> in-deA i,-,��tfrr ! <br /> tall <br /> Application is hereby made to Ban Joahis <br /> 4uinC� tuinocounty ordinance rmit to nNo. 549struct and1862sand theeRules a.ndeRegulationsao`Nan�, �V; <br /> application is made in compliance vith SanQ <br /> Joaquia Count Public Health Services. I� City Lot Size/Acreage <br /> s <br /> Job Address , i <br /> e � � Phone f <br /> Address. t <br /> Owner's Name <br /> 111, / Phone <br /> Address ® 40. R License No. <br /> Contractor WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ <br /> TYPE Of WELL/PUMP: NEW WELL ElOTHERD Monitoring Well <br /> PUMP INSTALLATION C SYSTEM REPAIR ❑ <br /> SEWER LINES �---- DISPOSAL fLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TAMC �--- OTHER WELLPITS/SUMPS <br /> _ FOUNDATION AGRICULTURE WELL . r-_ -- .« - - -• <br /> TYPE OF WELL EM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE pia. of Well Casing <br /> ❑ Open Bottom enlace Dia. of Well Excavation <br /> C! Industrial Type of Casing_ Specifications <br /> (,I Domestic/Private ❑ Gravel Pack L1 Tracy Type of Grout <br /> [-1 Other Cl Delta Depth of Grout Seal <br /> I'l Public S ace Seal Installed by <br /> I i Irrigation Approx. Depth I I Eastern State Work Done <br /> of Pum �. H.P. �� <br /> Repair Work Done (� Type p Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter f Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i RE PAIRlADDITION I I DESTRUCTION I 1 availabNo le'wi hin 200 fe�311ed if public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> d <br /> Number of living units: Number of bedrooms - Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity� No, Compartments <br /> StPTIC TANK ❑ Type/Mfg w• Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ti t Property Line , ---- <br /> Distance to nearest:-. Well Foundation <br /> Total length/size <br /> LEACHING LINE Cl No. & Length of lines LL Foundation Property Line <br /> FILTER BED [1 Distance to nearest: Well- r <br /> Size Number [ <br /> SEEPAGE PITS 11 Depth j Foundation Property Line�— <br /> SUMPS Cl Distance to nearest: Well = <br /> I,-- ��- <br /> an <br /> - DISPOSAL PONDS '"' ❑ '_ <br /> I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, <br /> rules and regulations of the San Joaquin County <br /> 11 Home owner olicensed <br /> n�ch manna gas turbecomcertifies <br /> subject the <br /> fliowing:o workman'srtcompensauon laws it that in the oof California." Contractor's Ih hiring or sub-contractinglsignlatuore <br /> employie any e person <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman s campens - <br /> tion laws of California." <br /> The applicant must caUAbr all required inspections. Complete drawing on reverse side. <br /> 40 IF}} Title: Date: <br /> Signed x <br /> ' R DEP T ONLY <br /> Date res <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: Sanunt- <br /> Joaquin <br /> aloHealth uPermiblic tl/Servicesealth vices <br /> 1445 N San Joaquin, p 0 Box 2009, Stkn, CA 95201 <br /> CK RECEIVED By DATE PERMIT'N0. <br /> FEE AMOUNT DUE, AMOUNT REMITTED CA <br /> INFO <br /> . EN 13.24 IREV.1/"5) <br /> EH Ib7a <br />