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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 /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby m�ade.to an Joaquin County for a permit t'a-eonetruct 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 Service. <br /> Job Address �4 ��� [ >^� City ACtWf Lot Size/Acreage `0 <br /> f iC-� Address ' oE '3 6Owner's Name � <br /> Contractor -&)I� _� mss Address B License No 37?71 Phone Y ' <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT DESTRUCTION;POut of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <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 /> L) Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation C Dia. of Weil Casing <br /> N Domestic/Private PeGravel Pack --❑ Tracy Type of Casing_ ob"C Specifications- � � f <br /> i'1 Public Cl Other n Delta Depth-of Grout'Seal Q Type of Grout fVII t7 \ <br /> ^I Irrigation Depth t -I IIEEastern Surface Seal Installed by <br /> Repair Work Done U Type-cf�Pump H.P. f -! '`` State Work Done _ <br /> Well Destruction ❑ We11%1 iameier �X* ming Material & Depth 4 \n` <br /> i Deptl? Filler Material & Depth ctrl 0 e <br /> TYPE OF SEPTIC WORK: NEW INS ALLATION I ] REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if puoV sewer,is <br /> available within 200 feet.►' y. <br /> Installation vWIl serve: Residence Commercial Other <br /> '_:Number of living units: ',7e'Number of bedrooms <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T' /Mf i` y <br /> ype g Capacity i- No. Compartments � <br /> PKG. TREATMENT PLT. ❑ t..fi i ` r, ;- Method of Disposal <br /> � ^'� <br /> }Distancet;to nearest: Well •Foundation- Proiperty Line <br /> LEACHING LINE ❑ !'No. & Length of lines :i )Total length/sizee <br /> f FILTER BED ❑ Distance�to nearest. Well Foundation �t }�. Property Line <br /> l <br /> I SEEPAGE PITS 11 depth Size L = Number j <br /> SUMPS LI Distance',to nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> --rules-and-reguiations of the San Joaquin,County _ <br /> Home owner or licensed agent's signature certifies the foilowing: "I certify tat iri ihb—Oerf6r—mance-cf•the-work-for-whieh-this-permit-is-issued;-t-shati-not----4--* <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 Ii We Of California." <br /> The applicant must ca I"for all squire inspections. Complete drawing on reverse side. <br /> Signed X Title: CXA. J_&X_ Date: __ r 473 <br /> i <br /> P EPARTMENT USE ONLY Q a { 9 u <br /> Application Accepted by Date �"-_� i r� Area [_L e V ' <br /> Pit or Gro" <br /> u Inspection byate Final Inspection by Date3 ? <br /> �} .. <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public-'Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> 3 <br /> INJFE AMOUNT DUE AMOUNT REMITTED CASH ECEIVED BY ATE PERM17'NO. <br /> • EH 13.24(REV.v n 51 A ? L' Q <br />