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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ` 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I� (Complete in Triplicate) I Application is hereby madel,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulationa of San Joaquin County Public Health Services. Job Address 1. City A4 ' Lot Size/Acreage �� ' fOwner's Name SO' "Address Phone .3� �. E' ` � nae No. Phone Phon II. 3 i Contractor Address TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well. ❑ PUMP INSTALLATION ❑ SYS�EM�IRCl OTHER ❑ Monltoring WellDISTANCE TO NEAREST: SEP'IC TANK SEWER LINESDISPOSAL FLD. PROP. LINE. FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 0NSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom •' ❑ Manteca Dia. of Well Excavation f Dia. of Well C Msing f:3 Domestic/Private ❑ Gflavel Pack ❑ Tracy Type of Casing_ f� Specifications IM QJ ii t/ Il Public fa Other F D Depth of Grout Seal . Type of Grout I I Irrigation it. astern Depth astern Surface Seal Installed by' _ t IN Repair Work Done 0 Type of Pump H.P. State Work pone II Well Destruction ❑ Well Diameter I Sealing Material & Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION IV DESTRUCTION'INo septic system permitted if 'public sewer is J I available within 200 feet.l Installation will serve: Residence Commercial Othery, ' r1� k Number of living units: � Number of•bi edro ms Character of soil to a depth of 3 feet: ` ` 'Water table depth SEPTIC TANK. PQ Tj pe/Mfg — ``r{- -- - Capacity • No. Compartments �I PKG. TREATMENT PLT. ❑ ,I� /t r Method of Disposal �M Distance to nearest: Well _ foundation Property Line LEACHING LINE No. & Length of linea ., �• 7o�1•len�gth/size l FILTER BED ❑ Distance to nearest: Well r4oFoundatipn �� Property Line ^ x- .� �I SEEPAGE PITS Depth 4VESire Number i .. — SUMPS Distance r St: Well, ` Foundation ;Property Line S--- DISPOSAL PONDS II. a 1 I hereby certify that I have prepay is plication an that'the workiwill be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the Sari Jo uin County '' ►` -.a .,:£.,1 ,_ -, • -%.. i/ 1 11 Home owner or licensed agent's signature dertifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 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- tion laws of California." II 1 -- - - " —I The applicant m call for all r quiredjr1spqC ns. Complete drawing on reverse Slide. I II �} Signed u�. i _ _.Title: Date: Z ff ` i Il I FOR DEPARTMENT USE ONLY M Application Accepted by �! Date 7 �n Area Z r 1 i Pit or Grout inspectionbye Date Final Inspection by 1 i Additional Comments: Applicant Return al.l copies to: San Joaquin County Public Health Services�� I Environmental Health Permit/Services I f E I 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IFEE NFO AMOUWT DUE AMOUNT REMITTED CK SH RECEIVED BY DATE PERMIT'NO. ikfkf EM 13-24 I REV.1/N 51 1 ■i� ""� 4'�„� D 72-R. +� / 7TEH 14.26 r L IP' I .i