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SAN JOAQUIN COUNTY. PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 s <br /> p 0 BOX 20Q9, STOCKTON, CA 95201 7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in ,Triplicate) <br /> made to San Joaquin County for a permit to construct and/or install the ules herein u ations of Sans <br /> application is hereby l <br /> liaSan riith Ban Joaquin County Ordinance No. 5Gq and 1862 and the Rules and Regulations <br /> application is made in camp .. ` , <br /> Joaquin County Public Health Se e . 1 ` ..3 Lot Size/Acreage <br /> city <br /> Jab Address A 23 f'7 Zen <br /> �;�. Q�o7C 0114S23 Phone S�4 '74 <br /> Owner's Name ` Address <br /> License No. -Phone <br /> Address <br /> Well <br /> Contractor WELL REpLACEME.NT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> NEW WELL ❑ OTHER ❑ Wel <br /> Monitoring <br /> TYPE OF WELL/PUMP! SYSTEM REPAIR C1 <br /> PUMP INSTALLATION ❑ ".� DISPOSAL FLD. PROP. LINE <br /> ' SEWER LINES �----- <br /> DISTANCE TO NEAREST: SEPTIC TANK —� + OTHER WELL PITS/SUMPS <br /> FOUNDATION --- AGRICULTURE WELL V <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Dia. of Well Excavation Specifications <br /> C7 Industrial ❑ Open Bottom El Manteca Type of Casing_ 4 <br /> L7 Tracy Type of Grout <br /> fa Domestic/Private ❑ Gravel Pack fl Delta Depth of Grout Seal <br /> i'1 Public [1 Other -}I ace Seal Installed by } <br /> 11 Irrigation r._..Approx, Depth l I Easter -�•.�,- --- state Work Done <br /> of Pump ���- <br /> H.P. <br /> Repair Work Done (.a TYPa pealing Material & Depth <br /> Well Diameter �— <br /> Well Destruction ❑ Filler Hateria . & Depth <br /> Depth <br /> available within 200 feet.) <br /> w� TYPE OF SEPTIC WORK: NEW IN �LLATIONE I k REPAIRlADDI710N I I DESTRUCTION INo septic system permitted if public sewer r +\ <br /> f ,. <br /> Installation will serve: Residence Commercial Other <br /> I Number of living units: Number of bedrooms -Water ' <br /> ' <br /> C Character of soil to a depth Tfyp3e�Nl1g C p y� No. Compartments <br /> SEPTIC TANK } Method of Disposal <br /> PKG. TREATMENT PLT. ❑ r� Foundation € -- Property Line <br /> ` Distance oto nearest:' Well I <br /> Total length/size <br /> LEACHING LINE Cl No. & Length of lines, k'- Foundation Property Line ---- <br /> t� <br /> _ FILTER BED `CI Distance to nearesf?e"''' Well------- <br /> ,) <br /> `1 Size Number <br /> SEEPAGE PITS ( I Depth Property Line <br /> ° <br /> SUMPS <br /> Ll Distance to nearest: Well Foundation -- <br /> ,1 <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, an <br /> rules and regulations of the San Joaquin County g work for <br /> Home oAnd agent's signaturecertifies the <br /> b oco loo wiorkman'srtcompensation laevysoof California." Contractor's rhui g othis P sub-contracting rct is englsignlatu�e <br /> employ uch manner as to <br /> certifies "I card that in the performance of the work for which this permit is issued, I shell employ persona subject to workman's compensation lawThe appl to all r aired to coons. Co plate drawing �\1,\ Date. r�' <br /> Title: <br /> Signed - <br /> f <br /> �DDE�PARTWIFAT.. SE ONLYDate tea <br /> Application Accepted by Date <br /> Pit or Grout Inspection byDate_. Fnal Inspection b <br /> Additional Comments-. rity <br /> in Joaquin <br /> Applicant - Return all copies to: EnvironmentaloHealthuPermit/Servicesv Services <br /> l 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> fCK RECEIVED BY DATE PERMIT NO, <br /> F FEE AMOUNT DUE AMOUNT REMITTED CASH r <br /> INFO IjI <br /> « EH 13-24IREV.r/n31 <br /> i <br /> CH 14-2a <br /> k <br /> z <br />