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4 ¢ <br /> 7 <br /> 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 /> 4 <br /> PERMIT—EXPIRES 1 YEAR FROM DATE ISSUED <br /> pcj�-"4� �eP4-f` f (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a Permit to construct and/or install the work herein described. This <br /> application is trade in compliance with San Joaquin County Ordinance No. 51+9 and 18 2 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address � S City Lot Size/Acreage <br /> Owner's Name . A _ Address _ -5!t:_ Phone <br /> ConlraclofmoG� ^�i - —Address �,, ' <br /> License NV7 OC f hone <br /> a TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIROTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation pia. of Well Casing <br /> ' eyDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Il Public 1.1 Other I-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Dept l I Eastern Surface Sertl Installed by \ <br /> Repair Work Done br Type of Pump H.P. cat State Work Done C-G <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth - Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) V <br /> Installation will serve: Residence .� .Comrnercial r^Other <br /> Number of living units: Number of bedrooms 111 f <br /> Character of soil to a depth of 3 feet: F Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ► „4V Distance to'ndaiest:' Well w foundation Properly Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i ' H I Depth Size Number <br /> SUMPS Ll 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 couniy ordinances, state laws, and <br /> rules and regulations of the San Joaquin County e _ <br /> Home owner or licensed agent's signature certifies the following: "I Certify that in the performance of the work for which tliis permit is issued, I shall not <br /> amp)oy 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 Ca' <br /> The <br /> mu must c Ir„for all requi• ni".ctio . Complele drawing on-rev rs side.- - <br /> Signed X Title: date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by CAt611V11.4f <br /> —,._.. Date J. Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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, CA 95201 <br /> FEE i <br /> INFO A OUNT DUE AMOUNT REMITTED CASH RECEIVED SY °" DATE PERMIT No. <br /> I t Eh 13-24IREV.tins � �� , <br /> EM u•ie I�+ .7" J Ll rC972 <br />