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N <br /> SAN JOAQUIN COUNTY'PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> S Application is hereby made to San Joaquin County for &.permit to construct and/or install the work herein described. This <br /> I 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 II Services. Q Job Address _1 _I,• ���v City Lot Size/Acreage <br /> Owner's Name Address Phone 1 J ?� <br /> ts <br /> 1 <br /> Contract o1MV=A(e6n)_I/—, ss License No. Phone Y 8 L_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT tl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR" OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> X <br /> ustrial ❑ Open Bottom ❑ Manteca Dia. of Well EMcavation Dia. of Well Casing <br /> �estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> blic Cl Other f"1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �.Approx. Depth I Eastern }] Surface Seal Installed by o- <br /> Repair Work Done L7 Type of Pump H.P. - 2 State Work Done <br /> Well Destruction ❑ Weil Dianvtet Sealing Material & Depth rr, <br /> Depth , Filler Material & Depth ; liA- if <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is w <br /> available within 200 feet.) <br /> installation will serve: Residence—_._ Commercial_ Other <br /> ,Number of living units: Number of bedrooms j <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 <br /> O <br /> LEACHING LINE ❑ No.°& Length of lines Total length/size _l <br /> FILTER BED"', 'Foundation---=------ -.Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Properiy Line <br /> DISPOSAL PONDS p 11 <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 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, k shall employ persons subject to workman's compensa <br /> tion taws of Calif !e." E <br /> The applicant u c I or a uired 'nspeetions. Complete drawing on rev a side's, <br /> Signed 1 <br /> Title: AW <br /> date: <br /> 0 D EPARTMENT USE ONLX <br /> Application Accepted byNr <br /> pare �' �� Area . Q <br /> f <br /> Pit or Grout Inspection by Data. Final Inspection by Date <br /> Additional Comments: i4 <br /> Appli•aartt' =�=Return--ail"copies't'v:'�San"Joaquiu Count`y`ptililic Healtti Services '"'-"� <br /> Environmental Health Permit/Services <br /> v 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED y CASHCK # RECEIVED BY DATE PERMIT'NO. <br /> Eli 13.24IREV.tins) <br /> 12 Ek 11.2EML rO"b (/� ids c+ ✓ <br /> PR <br />