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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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. <br /> Job Address !L)_L� l A_M,2,42X City��_(�,,� _ Lot Size/Acreage <br /> Owner's NaEil"Plyr <br /> t -���)�'j. ___-- Address s,�d hfi.�_ -._.._... Phone <br /> Contractor �+ Address r 611 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC ENT D DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ I <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 /> C-1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy y Type of Casing_ j Specifications <br /> Fl Public Cl Other 1­1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I i Eastern Surface Seal Installed by a �� <br /> Repair Work Done L] Type of Pump H.P. State Work Done v" <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth /Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I l DESTRUCTION i I (No septic system permitted if public sewer is V" <br /> available within 201 feet,) r, <br /> installation will serve: Residence_ Commercial— 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 ❑ Type/Mfg- Capacity No. Compartments <br /> PKG. TREATMENT PLT,❑ Method of Disposal ' <br /> Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED f Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number C <br /> SUMPS L.3 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 shell 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 /> tionlaws of Califor la." <br /> Thai =1icant m t call for all required inspesrctions. Complete drawing on never s. <br /> nTitle: Date: ' ? <br /> DEP RTMENT USE ONLY <br /> Application Accepted by CA./� 6666, <br /> PP Pte_ Date Area <br /> Pit or Grout Inspection by Date Fi I Inspection by Date <br /> Additional Comments: <br /> . � � ^ <br /> 3-4 <br /> Applicant - Return all copies to: San Joaquin County Public lth Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK • RECEIVED BY DATE PERMIT'N0. <br /> . EH 126IREV,,,K51 it to© a V <br /> EH 144,26 <br />