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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 t <br /> �p1 Gt►aZ 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 vith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address _ 072-9 A 0M00141 40 City �'��^ Lot Size/Acreage <br /> t �N �,P�/A <br /> Owner's Name_ . Address Phone t� <br /> Contractor Com`r C�nd� Address (I 3 r �7 ,_ License No. 7735 Phone3�T���Z <br /> TYPI OF WELL/PUMP: NEW WELL CI WELL REPLACEMENT DESTRUCTION Out of Service Neil ❑ <br /> j PUMP INSTALLATION 150-" SYSTEM REPAIR C1 OTHER © Monitoring Well '❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK S� SEWER LINES DISPOSAL FLO.0-0 PROP. LINE JP_ <br /> ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia c bf Well Excavation Dia. of Well Casin <br /> k Domestic/Private Gravel Pack C1 Tracy Type-of CAsin.g- : � _ Specifications `-y� ! <br /> FI Public fa Other (l Delta Depth of Grout`Seat _ f Type of Grout_CCAL� <br /> ! I Irrigation 'L,L.Approx. Depth I I Eastern Surface�Seai Instakled by +- <br /> Repair Work Done 0 Type of Pump S LIH.P. Z � � State Work Done—IqjQa L- [� <br /> " Well Destruction O Well Diameter �� .,., !Sealing Material i Depth-4 <br /> rr, Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial ; Other t <br /> Number of living units: Number of bedrooms <br /> wt 4 i <br /> Character of soil to a depth of 3 feet: A "' Water table depth <br /> SEPTIC TANK. D Type/Mfg Capacity No. Compartments <br /> + PKG. TREATMENT PLT. ❑ tMethod of Disposal (� <br /> Distance to nearest: Well f Foundation Property Line `\ <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil s°' Foundation. ,.P.roperty Line <br /> SEEPAGE PITS 11 Depth Size Number F <br /> SUMPS LI Distance to nearest: Weil Foundation R' ',.? Property Line <br /> DISPOSAL PONDS ❑ k <br /> fI hereby certify that I have prepared this application and;that'the work wilyPe done in accbrdarice with San"Joaquin county ordinances, state laws, and.­ <br /> rules and regulations of the San Joaquin County " <br /> } Home owner or licensed agent's signature certifies the following: "I cbrtifylliat 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 compenss- <br /> tion laws of California." t f <br /> The applicant must call for all required inspe,Ctions. Complete drawing on reverse side. =/ <br /> Signed x iY 41'S Title: OC,V O- p'~Z?-9t <br /> Date: <br /> 1. fNRDEPAIRTMENT USE ONLY-'_, <br /> Application Accepted by Area <br /> Pit or Grout Inspection b, Date "� + ` <br /> Pe Y., ��inal Inspection by ate;f Z <br /> Additional Comments: C I Ce,d l <br /> Applicant - Return all copse to: San Joaquin'County Public Health Servi a P <br /> Environmental Health Permit/Services t��l� Q }D q <br /> 445 N Sart Joaquin, P t7 Box 2009, Stkn, CA 95201 1 l <br /> IhFEFO <br /> E AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY .9/TE PERMITNO. <br /> h EM 13-24{REV.i i n 91 w/}� I r • � '� <br /> EH t4.25 2 111 t Q <br /> I � ' <br /> 77 <br />