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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 /> PERMIT EXPIRES I 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 /> Joh Address J �dr'- City ��-"� Lot Siz Crete <br /> Owner's Name r �� Address �Sy `- 0 S°/ JV Phone j <br /> Contractor k'�i S .� rC` ��" ee Address l _70/7- License No.,,� SUl-4 Phone iif � �bs <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT C, DESTRUCTION ❑ out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl <br /> Domestic/Private -- D Gravel Pack-} Ll Tracy ­Type of Casing_ Specifications <br /> I'1 Public I-1 Other n Delta ;� Depth of Grout Seal' Type of Grout <br /> I I Irrigation :=-:= I i Easterii Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H,P. State Work Done CQ <br /> Well Destruction D Well Diameter Sealing Material & Depth <br /> Depth ' Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1"1. AI ! DDITION I I DESTRUCTION l I (No-septic system permitted if ptiblic sewer is <br /> available within 200 feet.l <br /> " linstallation will serve: Residence_.__.. Commercial_ Other- <br /> Number of living units: --I— Number of bedrPoms 4 <br /> Character of soil to a depth of 3 feet: e`� Water table depth 7 S <br /> 5EPTIC TANK D Type/Mfga(S► f Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 67 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line t <br /> v <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to neare'k' '' Wall '` Foundation Property Line <br /> ```r .-: /t . <br /> R . <br /> • 5EEPS AGE PIT �• � DeplFi{�� Size-d 4/ Number <br /> SUMPS Ll �Distaht i to nearest, Well Foundation 10 It Property Line S <br /> DISPOSAL PONDS ❑ -_" <br /> I hereby certify that I have prepared this applidation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and F <br /> rules and regulations of the San Joaquin County () <br /> Home owner or licensed agents.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 subcontracting signature <br /> certifies the following: "I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa_ j. <br /> tion laws of California." ' ff <br /> The applicant must call for all required inspens. <br /> ctioComplete drawing on reverse side. <br /> Signed ? Zt Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> / � � <br /> Application Accepted by. Date Area 2- <br /> Pi ut , J <br /> o►GroInspection by Datt� Final Inspection by Date/�C, /?r <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 0 Box 2009, Stkn, CA 95201. <br /> FEE AMOUNT DUE AMOUNT REMITTED CA§H <br /> Cy'0RECEIVED BY DATE PERMIT,NO. <br /> INFO <br /> . EH 13.24[REV.r/A 6 V, <br /> EN 14.26 <br />