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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 /> S7 all 11 City Lot Size/Acreage <br /> Job Address <br /> Address Phone <br /> at' <br /> s Name t <br /> C dress License No. f:i Phone <br /> t r <br /> TYPE OF WELL/PUMP: NEW WE L ❑ WELL REPLACEM SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 <br /> T 5 DESTRUCTION ❑ Out of Service Well LI <br /> INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C'3I dustrial ❑ Open Bottom © Manteca Dia. of Well Excavation <br /> Dia. of Well Casin � <br /> mastic/Private ❑ Graver Pack Type of Casing-9- Specifications - �,• <br /> FPublic l 3 Ottiern Delta Depth of Grout Seal Type of Grout <br /> I I Irrigat�roF+ � Approx. Dept I E I ter Surface Seal Installed by <br /> Repair`.Work Done U Type of Pum H. State Work <br /> ti� i Sealing Material lK Aepth <br /> Well Destruction ❑ Well Diameter tt <br /> Depth-- Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I alvsiiableiw thin 200 feet.lsd if public:sewer is <br /> t <br /> i <br /> Installation will serve: Residence— Commercial_ Other IZA <br /> v - <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feat: Water tabEe.depthh t1 <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> t <br /> Method of Disposal ,^ <br /> PKG. TREATMENT PLT. ❑ - <br /> Distance to nearest: Well Foundation--�-=*Properly-Line� <br /> LEACHING LINE Cl No. & Length of lines <br /> __ Total length/size (� <br /> FILTER BED (-,]—Distance-to-nearest:- -..Well Foundation Property Line Q <br /> SEEPAGE PITS fl 1 Depth. '• dire Number <br /> SUMPS LI Distance to;nearest:-r YVell Foundation Property Line <br /> DISPOSAL PONDS 10 <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. `X <br /> Home owner or licensed agent's signature.cenifies the to `X <br /> 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appfica call r inspections: Complete drawing o revs side. <br /> S' rte 6& Title: Date: <br /> OR D RTMENT USE ONLY <br /> �._ q Area �� <br /> Application Accepted by Date [VAIL <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date[ <br /> Additional Comments: <br /> i 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 /> I � <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> IN:0 CASH <br /> P q�c 0 c7 �O� Z -36fl�, <br /> � . EH 13.241REV.+iasi <br /> EN 11.20 <br />