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SAN JOAQUINCOUNTY PUBLIC HEALTH SERVICES <br /> I <br /> ENVIRONMENTAL HEALTH_ DIVISION <br /> '445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �I 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 Sax� 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> Job Address City ,&14rle—CC—isot Size/Acreage <br /> h <br /> Owner's Name Address _ dt.t Phone <br /> ' I <br /> Contractor Addres License �3 �Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRS OTHER ❑ Monitoring Well I-] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDAT16N _.AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> x(Domasticf.Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications \ <br /> I'] Public t Cl Other n Delta Depth of Grout Seal Type of Grout <br /> — <br /> I I Irrigation _ Approx.FDe�' I ) Eastern Surface Seal Installed by <br /> Repair Work Done 9A5 Type of Pump H,P. State Work Done �G <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> • f Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION i I Mo septic system permitted it public sewer is <br /> ravailable within 200 feet.) <br /> i6 <br /> Installation will serve: Residence!"Commercial— Other <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfgr. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I fi . Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1M. <br /> LEACHING LINE C) No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well yp Foundation Property Line <br /> SEEPAGE PITS I ] Depth db Size Numher <br /> SUMPS L) Distance to nearest:; Well Foundation 'Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thisrapplication and that the work will be done in Accordance wi-6�San Joaquin-county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agei t!i 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 idhecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fotlowing: "I Certify that in the performance of the work for which this permit is issued, I shall employ parsons-iubject to workman's compensa- <br /> tion laws of California." /--� J1 r The a !t� , <br /> call for all require inspections .Complete drawing.'on.revs a ide. <br /> Signed Title: Date: <br /> n <br /> �' " R DEPARTMENT USE ONLY <br /> Application Accepted by Date Arse <br /> Pit or Grout Inspection by I� Date Final Inspection b FDatw O <br /> l;. <br /> Additional Comments: i <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> II 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> INFOFEE I <br /> AMOUNT DUE �`p! AMOUNT REMITTED CK RECEIVED BY D TE PERMIT-NO. <br /> r <br /> EMI <br /> 3.74 tttEY. x S <br /> EH 14.26 <br /> I! - <br />