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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application ie hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> ' application is made in ecwliance with San Joaquin County Ordinance No. 5h9 and 1852 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r� <br /> Job Address <br /> ity Lot Size/Acreage <br /> Owner's Name Address — <br /> ✓✓ Phone <br /> Contractor Address T/ '��;'0 <br /> License No, . Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION C7 DESTRUCTION Cl Out..of Service Well ❑ <br /> SYSTEM REPAIR W,, . OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL. FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE EA CO TRUCTION SPECIFICATIONS <br /> 17 Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation <br /> 1:7 DomasticlPrivate ❑ Gravel Pack L] Tracy T f CasingDia.of Well Casing [� <br /> i'I Public 1-1 Other 17 Delta Depth of Seal Specifications <br /> I I IrrioationTYPe of Grout Q <br /> —.Approx. Depth II Ess n Surface Seal Insta Q <br /> Repair Work Done 0 Type of Pump H <br /> Well Destruction ❑ Well Diameter a LC t <br /> Depth j PFil r 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAPO 01WI <br /> � isic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial---over Iefed or inspected within 2210 feet.) <br /> f <br /> Number of living units: Number of bedrooms E f i, �y <br /> Character of soil to a depth of 3 feet: E v1rQr!m''« t.Health 1 DIV,01 � <br /> SEPTIC TANK ❑ type/Mfg ater table depth <br /> PKC. TREATMENT PLT. Ll <br /> Capacity No. Compartments `1 <br /> _ <br /> # Method of-disposal' <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE L1 No. & Length of lines <br /> FILTER BED Total length/size <br /> ❑ Distance to nearest: Wall Foundation "Property Line <br /> SEEPAGE PITS I I Depth Size <br /> Number <br /> SUMPS <br /> L1 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS p Property Line <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, and <br /> rules and regulations of the San Joaquin County i _ _ <br /> Home owner or licensed agent's sigriaitiie centiles 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 Califo is.- t <br /> The applicant u ca for allJpact' <br /> quit nsonsComplete drawing on reverse side. <br /> KSigned X j i <br /> Title: ' <br /> Date: <br /> '. DFP RTMENT USE ONLY <br /> Application Accepted by <br /> bate_ r = + Z Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Data <br /> Additional Comments: <br /> 0 Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin,.p 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO r.CASH RECEIVED BY DATE PERMIT'NO. <br />. EH 17.2 IRE4r.Iiw51 t �' La7c7 C+^ i <br /> EH t{•2a 6 �jr ^ t <br /> 7 Yd o l a'R-�G� `�t71G. <br />