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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 0 BOX 2009, STOCKTON, CA 95201 <br /> i <br /> PERMIT E%PIRES 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 /> ! <br /> City � Lot Size/Acreage <br /> iJob Address <br /> Owner's Name/vt �.- - - <br /> �,{{ ��(( n tiA) -{ Address Phone <br /> Address Q +dnLicense No. 20 <br /> Contractor Phone <br /> TYPE OF WELLIPUMP. NEW WELL'` ❑ WELL REPLACEMENT Cl DESTRUCTION L1'Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER 01 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PI5/5UMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specrf�cations <br /> Type(a Domestic/Private ❑ Gravel Pack ❑ Tracy T yP of Casing_ Type'of Grout <br /> 4 I'1 Public C} Other n Delta Depth of Grout Seal <br /> I I hrigauon �^,.Approx. Depth I t Eastern Surface Seal Installed by <br /> Repair Work Done � . Type of Pump' > .H.P. ` State Work Done <br /> T <br /> Sealing-MAteriel-&•Depth m "� <br /> Well Destruction ❑ Well Diameter - Filler Material & pepth # <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION 1No septic system permitted if prrbli sewer is <br /> µ ��f""^ available within 200 fee <br /> � Ct,i <br /> ,. -,.. <br /> Installation will serve: Residence ommercial- Other <br /> Number of living units: L�Number of bedrQarr�s ! <br /> C(_ r. _ Water table depth <br /> Character of soil to a depth of 3 feet: I r <br /> SEPTIC TANK. ®-hype/Mfg 0 t `'-" Capacity�i� No. Compartments <br /> of Dispsal <br /> PKG. TREATMENT PLT. ❑ I F l (ss Method <br /> Distance to nearest: Well Foundation1�( '`'Property Line <br /> LEACHING LINE & length of tines � i Total length/size <br /> :{ <br /> FILTER BED ,«n Distance to nearest : Well Foundation Property Line 1 <br /> Number I f <br /> SEEPAGE PITS Ipt =�'" Site { -4 <br /> SUMPS- -* "A L! Distance to nearest: Well ; Foun ion Property Line <br /> DISPOSAL PONDS ❑ <br /> t I hereby certify that I have prepared.this application and that the work will t; done in accordance with San Joaquin county ordinances, sate 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 ss to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifi a following: " ertify thatain the performance of the work for which'this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion lawn o aiifornla" } <br /> The applica t ca for t m ns 'Com at yawing onAvirse side. tom/ t <br /> J VSigna ills: Date: <br /> FOR DEPARTMENT USE ONLY p �'1 <br /> Application Accepted by Date -" Area <br /> 1 <br /> Date Final Inspection by t Date' <br /> Pit or Grout Inspection bym s <br /> ' Ad -� �,r.fr�-�r`�'[ b/�.q1'471. i - <br /> Additional Comments: o # <br /> Applicant - Return all copies to: San Joaquin County Public Health Services f <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 r <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> INFO ] ] �J 3 <br /> . EH 13.24(REV,I/x si E� [ 33 t � / ` Q ` <br /> r EH 14.M L� - <br /> k <br />