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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISXON <br /> 445 N SAN JOAQUIN-,,,PHONE (209)468-3420 <br /> e P O BOX 201094 STOXTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11 (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 /> D � 1 City(�G t Size/Acreage <br /> Job Address <br /> Owner's Name `S Address <br /> Q Phone 1M1 <br /> Contractor 4 •� Address License No.l Phone <br /> TYPE <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION o Out of Service Well ❑ <br /> SYSTEM REPAIR 1+—� OTHER 11Monitoring Weil. ❑ <br /> PUMP INSTALLATION O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES; DISPOSAL FLD. .PROP. LINE r t <br /> kid `. <br /> FOUNDATION AGRICULTURE1INELL = OTFIE#i IM17ELL PITS/SUMPS <br /> INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> Dia. of Well Excavation Dia. o} Well Casing <br /> Cl Industrial C7 Open Bottom El Manteca <br /> C.7 Domestic/Private ❑ Gravel Packl C] Tracy Type of Casing_ Specifications <br /> I'1 Public is Other n Delta Depth of Grout Seal Type of Grout N ' <br /> I I Irrigation Approx. Depth I I E stern Surfac al Installed by <br /> � � H.P. ��» State Wark Done Teat ' <br /> Repair Work Done Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth i Filler Material dr Depth ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION i I iNo septic system permitted if public sewer is <br /> available within 2Q0 teet.i <br /> Installation will serve: Residence ° Commercial_ Other <br /> Number of living units: Number kbedrooms f �L , <br /> Character of soil to a depth of 3 feet: <br /> I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ' •;Capacity<_r •�- r --.No. Compartments ' <br /> Method of Disposal <br /> PKG. TREATMENT PLT. C] !! <br /> Distance to nearest: Well Foundation TProperty Line m? <br /> LEACHING LINE Cl No. B Length of tines Total length/srize1� ! <br /> . i <br /> ' FILTER BED ❑ Distance to nearest: Well Foun tion _ Properly-Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance t 1 nearest:• Well Foundation = _� Property Line <br /> DISPOSAL PONDS ❑ ; <br /> I hereby certify that I have prepared this `application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquinl County <br /> Home owner or licen agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t,shall not <br /> employ any par in suc nner as to'beeome subject to workman's compensation laws of.California.".Canttactot's hiring or sub contracting'signature <br /> certifies the t owin 'Ice dy that in the performance of ork for which this permit is issued, I shall employ persons subject to workman's cimpensa- <br /> tion laws a Californ I i r <br /> The appli ant mus it requi i Piet yawing on r side. a: <br /> Signed <br /> Title: Date: <br /> PARTMENT USE ONLY r <br /> Application Accepted by Data <br /> Pit or Grout Inspection by , Date Final Inspection by Date <br /> Additional Comments: t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services f <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, 8tkn, CA 95201 � <br /> FEEY <br /> INFO AMOUNT DUE �� AMOUNT REMITTED K RECEIVED BY ATE PERMIT NO. � <br /> + EH 53$4 IREV.I/h 51fR >; <br /> EH 14.21 t <br />