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SAN JAWIN COUNTY PUBLIC HEALTH SSICES 3p� (njS <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 in made In corripllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public �Hryealth Se"ices. �.1.�,f.1..r,� <br /> Job Address 3'5(5- Kh\14 o City `� MV—ti! „ Lot Size/Acreage <br /> Owner's Name S('lC( I I• ( Address PD POY LW7T>—r C©hCD/4 Phone CC 'Ir <br /> TTS `tc 42 lr0 7�5 <br /> Contractor <br /> t t/✓ � Address Z-E It '� I`+•Er srw icense No. �Z7� Phone g � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION q � SYSTEM REPAIR ❑ OTHER 1) . Monitoring Well <br /> DISTANCETO NEAREST: SEPTIC TANK �l� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION (� ty" AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �'// <br /> "❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L Dia. of Well Casing <br /> 17.1 Domestic]Private ❑ Gravel Pack ❑ Tracy Type of Casing_I +a PVG Specifications 5-50v 5arf� <br /> I'I Public �❑�0OSher f-1DeltaDepth of Grout Seal �^ Type of Grout N2a Leernenr V\ <br /> I I Irrigation ;�w Approx. Depth ( I Eastern Surface Saul Installed by <br /> Repair Work Done ❑ Type of Pump - H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter `r Sealing Material L Depth <br /> Depth Filler Material 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence <br /> Number of living units: _ N Post-ir Fax Note 7671 Dat pages <br /> Character of soil to a depth of 3 N To From de.depth <br /> SEPTIC TANK ❑ Type/1 oartments <br /> Co.Dept 'sai Co. <br /> PKG. TREATMENT PLT. Cl (b d Disposal <br /> Distan Phone# UPh # <br /> F by J �.75� Fax `G <br /> LEACHING LINE ❑ No. b <br /> FILTER BED ❑ Distan --- <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> 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, 1 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 applican call for all,requireeigj�inspectlons. Complete drawing on re <br /> � Sidd �QL/q 7 p/ <br /> Signed X //" — �itle: Date: '" -IS <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 110 IA <br /> r Area Zve A)p C,�S h <br /> el( <br /> Pit or Grout Inspection by /y_ ,.J Date Final Inspection by Date <br /> Additional Comments: Al W ��u c1 at✓ LL) —Z- <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services ,'LCJa BI <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 OO �� <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> INFO <br /> EH I7-7N(REV.i/xai 066 p(UE� PJ L 7/td� ap6S7 <br /> EHNM <br />