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E <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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 cc4liance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> cit �/ <br /> y !v ^" - <br /> Job Address Lot Size/Acreage ' - <br /> Owner's Name I. Address gz�iPhone /?'Y/ <br /> ' Contractor 'T I7AA1-_Address ` License No. PhoneA��� +4: <br /> TYPE OF WELL/PUMP: �I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL PR06LEM AREA CONSTRUCT ECIFICATIONS <br /> C) Industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing <br /> �a Domestic/Private ❑ Gr Private Pack ❑ Tracy ype of Casing_ Specifications <br /> i"1 Public (.7 DiIher 1-I Delta Depth of Grout Seal Type of Grout <br /> 1 I irrigationI <br /> Approx. Depth 1 I stern Surface Seal Installed by <br /> Repair Work Dons C3 Typel of Pump _H,-A.. -- - - - State Work Done " 'U.7 <br /> I Sealing Material 6 Depth <br /> Well Destruction ❑ Wei:!Diameter - <br /> Deph Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION4 Mo septic system perrr'iiftid=tf--public sewer is <br /> .I1 available within 200 feet.) <br /> Installation wili serve: Residence_ Commercial -^ Other'-", - <br /> Number of living units: Number of bedrooms ` <br /> Character of soil to a depth if 3 feet: Water table depth ° <br /> SEPTIC TANK. ❑ Type/MfgCapacity :! No. Compartments <br /> PKG. TREATMENT PLT. ❑ II`, Method of D-isposal <br /> 0 <br /> Distance to nearest: Well Foundation Properly Line <br /> .� <br /> ' LEACHING LINE ❑ No. & Length of lines Total Length/size <br /> t FILTER BED ❑ Distance to nearest; Weil Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation` Property Line <br /> DISPOSAL,PONDS ❑ I� <br /> I hereby certify that I have prepared this application dnd'that the work will be done inaccordance with-San Joaquin county ordinances, state laws, and <br /> rules and regulations of the SeA Joaquin County 4 <br /> Home owner or licensed agent's signature cenifies the following: "I Certify that in the performance of the work for which this permit is issued, I 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_Calif ornia."-..-.,. <br /> l The applicant t call for all.r' vire i cti Complete drawing on rev se side. <br /> j <br /> Signed X Title: _ajiDate: ( "11'9 Z__ <br /> H" OR DEPARTMENT USE ONLY G { <br /> Ap nation Accepted by II - Date �- `� Area <br /> f Pit or Grout Inspection by ;I� 4 Date Final Inspection by Datey <br /> i <br /> Additional Comments: 1 f�-�� &I bP/ A^""4 M404d � <br /> 'Il <br /> Applicant _ Return all copies to: San Joaquin County public Health Services <br /> Environmental Health Permit/Services <br /> I. <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ;� e <br /> FEE :` Kill <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PEitM1T'No. <br /> ou <br /> . EM 13-24IREY.t/AsI ;Ir <br /> EH 111-U BY <br />