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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION 1 <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 /> a4 (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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. n R <br /> Job Address _ CAA(S 4y '`� - — City Com_ Lot Size/Acreage <br /> E' Owner's Namei �x 'OF�eT Address Phone - <br /> Contractor 1�^ CA(WC-eAddress�6�� �la�o� +4V� !� � <br /> License No7 /8 Phne 921 � <br /> �o8 <br /> TYPE OF WELL/PUMP: NEW WELL El.- WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ <br /> PUMPANSTALLATIONwd SYSTEM-REFAIR_❑ 01HER-0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL71<VRE WELL OTHER WELL PITS/SUMPS ; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA:—ONS TRUCTION SPE FICATIONS <br /> kCl Industrial ❑ Open Bottom",) ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> -� <br /> C1 Domestic/Private Cl Gravel PackL7 Tracy Type of Casing_ Specifications r <br /> 1'I Public 1:1 Other fl Delta Depth of Grout Seal Type of Grout j <br /> I I Irrigation_ _.Approx. Depth I }Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter =Sealing Material 4 Depth X, <br /> I � <br /> Depth Cjiller Material 6 Depth <br /> h tTYPE OF SEPTIC_ WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is t " <br /> available within 200 feet.I } <br /> Installation will serve: Residence Z Commercial Otherti aY <br /> 'um r of'livi6v <br /> Character of soil to a depth of 3 feet: vrz Water table depth <br /> SEPTIC TANK 9' Type/Mfg Capacity V No. Compartments Il <br /> ?KG. TREATMENT PLT. ❑ i f i Method of Di al ' y <br /> Distance to nearest: Well �`.) - Foundation-= -S—Property-L-ine--5�U^' t <br /> LEACHING LINE PP ND. & Length of lines f i ~Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 1 � Foundation 3 .Property Line SV <br /> SEEPAGE PITS 11 Depth Size Number- <br /> SUMPS L1 Distance to nearest: Well Foundation - Property Liner <br /> DISPOSAL PONDS ❑ 1 <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 <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 tobeco ubiect to workman's compensation laws of CaliforRia." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the poodo ante of the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu II for all req inspe Ions. Complete drawing onreeverse"side. ' <br /> Signed X Title: - -irL _ Date: <br /> FOR DEPARTMENT'USE ONLY <br /> Application Accepted by 'bate_ k t, f.na�A;.:t�sti -�-?; 'bate ��^ " Area >2 U - PI <br /> Pit or Grout Inspection by Date Final Inspection by����A Date 6't <br /> Additional Commenia: -b Attl # <br /> 9 Applicant - Return all copies to: San Joaquin County Public Health Services I <br /> I Environmental Hewit-h Permit%Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 t <br /> FEEAMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASRECEIVED BY DATE PERMIT'NO. <br /> H � <br /> 4CH 3-24 I <br /> EN 114.26 IREv. 1"slSki t s , _ 1 ;710.?y lel-r­ 3- 3 <br />