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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 /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heresy 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 /> gjla �.. City Lot Size/Acreage <br /> 4 Job Address <br /> Address o Phone <br /> Owner's Name 3�i L] <br /> 't3 Phoneco <br /> ,L� <br /> GonGactor Address !C 2 License Na <br /> k of Service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑- / WELL REPLACEMENT C7 DESTRUCTION L1 flit Monitoring Well <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA r CONSTRUCTION SPECIFICATIONS1Nell Casing <br /> C7 Industrial T ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> g- <br /> Type of Casing- Specifications <br /> �estic]Private ❑ Gravel Pack C] Tracy Type of Grout <br /> [1 Public I.] Other Cl Delta depth of Grout Seal YPQIQ <br /> I I Ifrigation —,Approx..Depth `I6I Eastern Surface ea nstalled by r <br /> Repair Work Done U Type of Pump ___ H.P. State Work Dane <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I- DESTRUCTION I I afvailablerc system permitted wthin 200 feet.I it public sower is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of,soil to a'depth of 3 feel: 4 <br /> C <br /> SEPTIC TANK. ❑ Type/Mfg � apacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. Cl s a•` I <br /> Distance to nearest: Well ;Foundation " Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED _ wCl Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f <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 Sen Joaquin County <br /> k 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 /> I 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 laws of California." <br /> The applica t Call for all required ins Ction omplete drawing o rse ide. <br /> [ /s�•-g�. <br /> Signed X Title: �� Date: ill <br /> Z2:=Y <br /> Application Accepted by Date - Area <br /> 21 <br /> Pit or Grout Inspection by Date Final Inspection by ate-�� <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, GA 95201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO.' <br /> INFO <br /> - <br /> EH 14.26 III 7 <br />