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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.lto 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 <br /> Job Address I City Lot Size/Acreage <br /> Owners.Name Address Phone <br /> Contracte> Address License Ifo. Phone <br /> TYPE OF WELL/_P_UMP:_, NEW WELL 13 WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well L1 <br /> 1.,,, Monitoring Well <br /> ' PUMA? INST41_LATION El SYSTEM REPAIR C7 OTHER D C7 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> 1 FOUNDATION " AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> u <br /> 'E <br /> INTENDED USE TY4 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I } <br /> nindustrial C3Open Bottom �..� �E] Manteca Dia. of Well Excavation Dia. of Well Casing °. <br /> Il Domestic/Private 111 Gravel Pack C7'Tracy Type of Casing_ Specifications <br /> UI Public !:1 O(her---�'—" 171`Delta Depth of Grout Sea! Type of Grout <br /> { Approx. Depth 1.1 Eastern Surface Seal Installed by <br /> I Irrigation 'N- ____ <br /> Repair Work Done L7 - Type f Pump H.P. State Work Done <br /> Well Destruction C] Well Diameter Sealing Material & Depth ' D <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I IEPAIRlA OITION DESTRUCTION l I lNo septic system permitted if public sewer is (y� <br /> available within 200 feet.1 Q <br /> Installation will serve: Residence Commercial_ Other 4 <br /> Number of living units: •.M' Number of_, <br /> Character of soil to a depth ofi3 feet: Water table depth 1 <br /> SEPTIC TANK. ❑ Type/IVlig : ' Capacity No. Compartments; <br /> �iIN _ <br /> PKG. TREATMENT PLT. L`l a" �,r Method of Disposal <br /> . ; Distance to.nearest: Well Foundation Property Line_ ^� <br /> 1 - 1" <br /> i <br /> t.LEACHING LINE No. & Length of lines Total length/size HoX " <br /> %FILTER BED '. ❑ D'i once to nearest: Well SO Foundation , 10 + Property Line (n <br /> SEEPAGE PITS 1 i Depth Size X ' } dumber ti <br /> SUMPS _ Distance to nearest: Well 00-t Foundation =" ♦w Property tine---,S w <br /> DISPOSAL PONDS ❑ IN <br /> I hereby conif0hat I have prepared this application and that the_woik will be,done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sari"Joaquin County _ <br /> s' <br /> Home owner or licensed agent't;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 AriVry art's compensation laws of California." Contractors hiring or subcontracting 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-lows of California."- <br /> J� <br /> The applicant t call for 1 qu' d inspections. Complete drawing on reverseqS <br /> Signed X AA Title: • a Date: <br /> IL <br /> FOR DEPARTMENT=SENLY rr <br /> Data 7� Area �f <br /> Application Accepted by <br /> t � � <br /> Pit or Grout Inspection by I� Date Final Inspection by ate <br /> Additional Comments: II <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 /> t <br /> FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO / [� ,r-,� r r \ Qy ,.� [, Q <br /> . EH 13-24 4REV,t i x 51 C 7 �- U " r!`7 `CTU I Oaf /._„�r� �'7 -3 L'��©� <br /> EH 14.20 v <br />