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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f v.) Z <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN* PHONE (2092468-3420 1 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t 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 /> • Joh Address I/ ✓ City Lot Size/Acreage <br /> /Yl� (/ Address / `�` ~- - -_ - <br /> owner Name Phone <br /> ' Contractor �� 'Address 'r License No._`LF�� l —Pham <br /> TYPE OF WELL/PUMP: NEW WELL G WELL REPLACEMENT DESTRUCTION t oof-Service-Well ❑ <br /> Monitoring .Well <br /> PUMP INSTALLATION Q' a SYSTEM REPAIR C�- , OTHER G r . C7 <br /> DISTANCE TO NEAREST: SEPTI�/INK SEWER LINES _DISPOSAL FLD� ,moi PROP. LINE <br /> FOUNDATIONa�AGRICULTURE WELL OTHER�WELL _ .PITS/SLUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION_SP_ECIFICATIONS <br /> C-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia o Well Casing <br /> _ f� <br /> �YDomesticlPrivate ravel Pack7 i0 Tracy —Tgpe of Casing_"" I Specifications X <br /> I'1 Public Cl Other F1 Delta Depth of Grout Seal= " -Type—of-Grout <br /> I i Irrigation AS, Approx. Depth 1 I Eastern x _S r ce Seal Installed-by <br /> Repair Work Done U Type of Pump /---� H P_ ' eSt to Work DanAtre <br /> Well Destruction <br /> "WeII`Diameter" _{ Sealing Material B.Depth? 7 " � <br /> ` � <br /> Depth //� � � Fille�_Materiel-&--Depth _ ___ -� < <br /> _ r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l�ERAIR/ADDITION I I f-ODESTRUCTION I'1 INo.seplic sy`siem.pWn1"_16d_d public-sewer is' <br /> .A ib ..'"" available within 2t0 feet) i' F. <br /> f i .:r <br /> Installation will serve: Residence— Commercial_-Other <br /> Number of living units: Number of bedrooms =e l6 <br /> `' h <br /> � f <br /> Character of soil to a depth of 3 feet: - — ii "�"' may" —e Water table depth <br /> SEPTIC TANK. 0 Typ4iMfg - - _ Capacity. ./No. Compartments <br /> PKG, TREATMENT PLT. ❑ r Method of Disposal <br /> 4 <br /> ",Distance to nearest: e11 <br /> V' r _ <br /> LEACHING LINE, ❑ No. & Length of lines Total length/size <br /> FILTER BED (D Distance to nearest: Well Foundation Propeny Line <br /> i - <br /> r SEEPAGE PITS I I Depth i Sire Number <br /> SUMPS L1 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 f' , <br /> Home owner or licensed agent's signature oenifies 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 becorne subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature v.. <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 /> -s The applicant ust req ' ed ' ions. Complete drawing on revers 0. <br /> Signed K Title: Date: <br /> u FO EPARTMENT USE ONLY <br /> Application Accepted by Date / � Area <br /> Pit or Gro inspection by Mal Date L Final Inspection by �2_ <br /> e 1r <br /> l: Additional Comments: 4 01 ` <br /> Applicant - Return all cop es to: SaflvfTorittuin County Public Health Service <br /> t Environmental Health Permit/Services <br /> 445 N SanlJoaquin, P 0 Box 2008, Stkn, CA 95201 <br /> FEE AMOUNT-DUE k AMOUNT-AERECEIVED NI&ED ,, CASH EIVED BY DATE, <br /> IP T <br /> r LIQ J , ` .0 <br /> EH 11.26 <br /> .. a0, - <br /> - _��-- <br /> ' - 9a <br />