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S ...,JOAQUIN COUNTY PUBLIC HEAL�I,.WSERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 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 9 73 G-eJ. City a•z� Lot Size/Acreage <br /> Owner's Name /1 t �' l r� ' Address ye Alxz� phone b U Q 0 74— <br /> Contractor Addres,(,/S4? License Nq�6�1�? Phoney <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well <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 /> f.l Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Dept I I Easternurface Seal Installed by <br /> Repair Work Done (i3' Type of Pump H.P. State Work Done –�- <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth <br /> Filler Material & Depth LJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t� <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth �S <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments _ <br /> rfi <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well _ Foundation Property Line <br /> �Ay EN <br /> SEEPAGE PITS 11 Depth Size _ Number RECEIVED <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 -BAR 2 9 °5 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coun$iAbldbQA06JIWaWJ4"X1Ilrnd <br /> rules and regulations of the San Joaquin County PUBLIC HEALTH SL.RVICES <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for wP.NqI40NTf1 MjipJi"frt,- , tr <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting slgnattUe�rl <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 mus II f r all required 'nspections. Complete drawing on-reverse side. <br /> Signed X : _�/�/ Date: r / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by O j i, '),- Date <br /> Pit <br /> J 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 D��O <br /> Environmental Health Permit/Services U ,�`Y'I <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> r FEE AMOUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMIT NO. <br /> INFO — <br /> . EH 13-24 IREV.1/n51 <br /> EH 14.25 <br />