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l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 <br /> ENVIRONMENTAL HEALTH DIVISION �(�,'CPO <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 ` <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> F (Complete in Triplicate) <br /> Application is her8by 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. t <br /> r � r <br /> Job Address J�eity hot Size/Acreage9fi�,�--� # <br /> f A <br /> Owner's Name « Address j.S f 7J� � Phone <br /> Contract r9Address License No, tj �d Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R CEMENT C} DESTRUCTION ❑ Out of Service Well 0 <br /> 'PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <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 /> Q.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'i Public' El Other F1 Delta Depth of Grout Seal Type of Grout <br /> 13.Irrigation — Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth - -- <br /> f Depth Filler Material &-Depth• <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION JV DESTRUCTION Wo septic system permitted if public sewer is <br /> ,available within 200 feet.I <br /> installation will serve: Residence X�. Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth 4 <br /> SEPTIC TANK Type/Mfg f Capacity T 49, Na. Compartments �. <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:'—V-Well Foundation Property Line <br /> f LEACHING LINE Cl No. & Length of I es _ _ -.)-In � __ Total length/size + <br /> FILTER BED ❑ Distanceto nearest; Wall 1� Foundation- ,�( f _ Property Line <br /> F <br /> SEEPAGE PITS - l, DepthM Sire .. ° ' "-"-` Number__5 r'�"-' <br /> SUMPS fQ Distance to nearest:. Well �Q Foundation J O Property Line <br /> DISPOSAL PONDS ❑ u/Y175" d t+� <br /> I hereby dertify"ihat 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 <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 r <br /> employ any person in such manner as to become subject to workman's compensatibn.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 California." <br /> The applicantust c for required ' s ions. Complete drawing on reverse side. <br /> t <br /> Signed X Title: __9- __ _ Date: a �� <br /> FOR DEPARTMENT USE ONLY <br /> -�o-9 <br /> Application Accepted by Date __ z Area <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> =�Z <br /> Additional Comments: eZl o 0 f ►"rr� fI✓l G <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 /> IFFO AMOUNT DUE AMOUNT REMITTED CASH11 RECEIVED BY DATE PERM17'NO. <br /> + EH 13.24(REV,I/x sl <br />