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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 /> v CitLot Size/Acreage <br /> Job Address y <br /> Owner's Name Address Phone <br /> "^ —Cbrttactot- - - .-Addtess-l'' -License No-I-�_�- _ -P-hone. <br /> TYPE OF WELL/PUMP: `^t NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ k <br /> 'PUMP INSTALLATION._❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINESrS.,.I — <br /> INTENDED <br /> D SAL FLD PROP. LINE <br /> FOUNDATION AGRICULTUREOTHER WELL PITSISUMPS 6 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA COSPECIFICATIONS 1 <br /> f7 Industrial' -0 Open Bottom ❑ Manteca :: <br /> vatio�Y Dia:of Weil Casing <br /> A'�fa Domestic/Private Cl Gravel Pack ❑ Tracy TyMSpecifications <br /> I'I Public 1-1 Other n Delta Deeal Type of Grout <br /> I I trrigation Approx. Depth l I_EasternSualled by Q} <br /> Repair Work Done U Type of Pump`- s "-= H•P✓ 6 State Work Done_ I= <br /> �. 'Seiling tenial & Depth y,] <br /> Well Destruction ❑ Well Diameter s J r <br /> Depth Killer Material & Depth i <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATION 1.1--REPAIR/ADDITION I DESTRUCTION I IrlNo septic system-permitted-if-public sewer is <br /> 4! " available within 200 feet) <br /> Installation will serve: Rssidence_z=z.� Commercial_; Other 3 <br /> Number of living units: Number of bedroo t r <br /> Character of soil to s depth of 3 feet: 3 star table depth <br /> SEPTIC TANK ❑ Type/M19 Capac y No. Compartments `b <br /> 1 <br /> "s PKG. TREATMENT PLT. ❑ e od of-Disposal ' <br /> Distance to nearest: Well Fou 0 Y <br /> I � � <br /> LEACHING LINE Cl No. & Length of lines Total length/size Yd , <br /> j <br /> FILTER BED b Distance to nearest: Well Foundation C! Property Line .` <br /> SEEPAGE PITS - I 1 'Depth., Sire Number <br /> SUMPS LI Distance ton rest: Well �oundation 2Property Line <br /> ` l! <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and That the work wilt tie done in accordance-with San Joaquin cotinty`6rdinances, 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 j <br /> 4 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 /> 4 certifies the following: "I certify that in the performance of the work for which this-permit islitsued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." *, `� <br />{ The applicant mu call for all r red inspect"ons, Complete drawing on reverse side. <br /> Signed X Title: Date: �/� <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by - Da <br /> t3 D 1 L Area <br /> Pit r Grout inspection by Pate 2''' Final Inspection by Date L 1 Z <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> k 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO 111-30 <br /> / <br /> . EH 13.24(REV.I1 5) c� J� r� / rt 4O b r /f 30 <br /> EH 14.20 J <br />