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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 1 <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 1$52 and the Rules and Regulations of San <br /> Joaquin Countyy 16-Public Health Services. <br /> q 0 0Age0�-�-- _.- Cit [' ag <br /> Job Address y 4� T�� Lot Size/Acre e <br /> Owner's Nam.V; yb �J ���IV+�t.1C Address r Phone 1s� r <br /> Contractor- - Address 4,10 h owA) Lyt/. ---- License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 171 OTHER q Monitoring Well L3 <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 /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing_ Specifications .� <br /> 0 Public Cl Other 171 Delta Depth of Grout Seal Type of Grout rV�� <br /> I I irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ® Type of Pump H.P. State Work Done <br /> Well Destruction O Weil Diameter Sealing Material & Depth <br /> Depth Filler Material 8 Depth NL <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION f I ~DESTRUCTION (No septic system permitted if public sewer is <br /> �- vailable within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number.of bedr oms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.,, 0 Type/Mfg. Capacity No. Compartments <br /> PKG>TREATMENT PLT. ❑ Method of Disposal <br /> .� <br /> Distanceto Weare !'' 'Wei Foundation Property Line <br /> 4 <br /> LEACHING LINE C1 No. & Lengthf 'n s Total length/size <br /> FILTER BED n Distance to ne est: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and L <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, 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 Caornle." 1 <br /> /The applicam ust call for all r ut d inspections. Complete drawing on raver side, <br /> /Signed X Title; n� ��' Date: � J0 <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area t <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> - I <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ` <br /> Environmental Health Permit/Services <br /> 945 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE <br /> v �" <br /> INFO AMOUNT!!lDDUE AMOUNT REMITTED CK RECEIVED BY O TE PERMIT'NO. <br /> . EM 13-24 MEV. 24, <br /> EN 14.26 <br /> i <br />