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iSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 4 ENVIRONMENTAL HEALTH DIVISION <br /> 445 -N SAN JOAQUIN PHONE (209)468-3420 <br /> P 0 BO%2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coWliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �tO ' <br /> Job Address City � e/Acreage <br /> i <br /> �Q 3 > <br /> O er's Nam rU'� , Address ~�s/ + Phone 7 r <br /> r ! , O�F'1 I[ t Z L License No.r z Phone <br /> ^ + �� <br /> ConEractar i �. Bess_ r <br /> TYPE OF WELL/PUMP:'- NEW WELL ❑ WELL REPLACEMENT II DESTRUCTION Cl Out of Service_Well ❑ ; <br /> -PLUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST-PSEPTIC TANK _�� SEWER LINES DISPOSAL FLp. PROP, LINE 1 <br /> I <br /> ";FOUNDATION " GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE 6F 1.�- &L IAA0W M AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Ih�us rrai -: Open Bottom 1 Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> Cl Domestic/Private 0 Gra el,Pa�ck �y D- racy Type of Casing_ Specifications <br /> _ F- <br /> I'l Public - 1p.1 Other , ❑ Delta t Depth of Grout Seal Type of Grout ± <br /> I i Irrigation E App(ox. C � <br /> / epth I Earl$tern_, >� Surfa eul Installed by <br /> Repair Work Done LY�ype of Pump - H.P. State-Work-Don* - [rw <br /> Well Destruction ❑ -Well Diameter Seel ing tercel & Depth <br /> Eaepth Filler Material & Depth <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I 1 ENo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: .Residence___, Commercial— Other <br /> Number of living units: Number of erooms <br /> Character of soil to a I',*-, of of 3 feet: Water table depth <br /> SEPTIC TANK �__TypelMfg C acity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well oundation Property Line <br /> LEACHING LINE -8--' No. & Length of tines Total length/size r <br /> FILTER BED C-1-Distance to nearest. Wel Foundation Property Eine <br /> F <br /> SEEPAGE PITS E-1-Depth lie Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this app' ation and that the work 'I be done in accordance with San Joaquin county ordinances, state laws, an I <br /> rules and regulations of the San Joaquin urity <br /> Home owner or ficen agent �lgnature certifies the following: "I certify t at in the performance of the work for which this permit is issued, I shall <br /> employ any peso such fnann as to become subject to workman's mp sation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the foil ing: "i certify t t in the pe mance o e ork which t ' permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of litom! -" � <br /> The appfic t must all I requir late awing on r r ads. <br /> r , r <br /> Signed X Title: Date: <br /> I <br /> DEPARRTTMENT USE ONLY <br /> Application Accepted by G�" ' v �G Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant -- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDK H RECEIVED BY DATE PERMIT_NO. <br /> FO CAS <br /> . EH 3-24(REV. �� <br /> Em 14-20 �J �J <br />