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SAN- JOAQUIN COUNTY PUBLIC HEALTH SERVICES k <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> k <br /> P O BOX 2009, STOCKTON, CA 95201 <br />` PERMIT EXPIRES I YEAR FROM DATE ISSUED � <br /> i (Complete in Triplicate) <br /> a <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 1$52 and the Rules and Regulations of San <br /> i Joaquin County Public Health Services. <br /> &(f/ �f City Lot Size/Acreage <br /> Job Address - <br /> & <br /> Owner's Name <br /> 9ak Address s e _— Phone <br /> ly �= �''. License no.3;P73K Phone 33y—y�L�' <br /> Contractor sP Address - —" <br /> TYPE OF WELL/PUMP. t NEW WELL �'"a WELL REPL,4CEMENTIC ` ` -DESTRUCTION•-L�"Out of Service well 0 <br /> Well Ll PUMP INSTALLATION SYSTEM REPAIR G7 y --� ~ wOTHER ❑ <br /> a0 =—SEWER+INESr :::� � DISPOSAL FLD.� PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _-- <br /> ---� C'-FOUNpATION AGRICULTURE WELL OTHER WELL `- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /! <br /> n Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation 1 Dia. of Well Casing <br /> `5ZDomestic/Private Gravel Pack 0 Tracy Type of CasingSpecifications. <br /> _ <br /> e o1 Grout <br /> 1'! Public [:1 Other 61 n Delta Depth of Grout Seal <br /> r�7 ��Fyp <br /> • <br /> i I Irrigation 30 Approx. Depth I I Eastern Surface Seal Installed by <br /> cobf <br /> Repair Work Done U Type of Pump <br /> H.P Sealing Material Depth <br /> State Work_Done& f <br /> Wall Destruction Well Diameter - 1�['r <br /> 4f�❑i <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I i JNo septic system permitted if public sewer is � <br /> r available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other r- ,._, _•� <br /> Number of living units: Number of bedrooms i <br /> t Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. �, ❑ Type/Mfg <br /> Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PCT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE-' D_No.-&A-L-ength'bf-lines nes - " �Toial length/size <br /> FILTER BED �•' ❑ Distance to nearest: Well Foundation Property Line w� `��� <br /> y <br /> SEEPAGE PITS R 11 Depth Size Number <br /> SUMPS Irl Distance to nearest: Well •._• � Ftsundation i Property Line <br /> t <br /> DISPOSAL PONDS El "` )A^ s <br /> I hereby certifyahat I,have prepared thik application and that the work will be.dona in accordance with San Joaquin coynty�otrdinances, state laws, and <br /> rules and regulations of the San Joaquin,'County �S1 <br /> Home owner or licensed agent's signature certifies,the following: 'iI 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 sutiiact to workm�n's_compensatian_1aw5of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for whiGh�•thisipe Mjj-is-issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant mus call r allfr uired,nspecti�ns. Complet�ewigg_on••reverse side-.per {t . <br /> Signed X G -moi. Title: `- Date: G-y--9�- — <br /> f <br /> ry- <br /> U <br /> FOR DEPARTMENT USE ONLY <br /> d <br /> fArea p <br /> Application Accaptr�d by Date <br /> Pito Grou napection by Date �� �Z' final Inspection by' Date <br /> T ` � <br /> Additional Comments- <br /> a. <br /> Applicant - Ret 11 c P es San o q n CO ty P. <br /> 1 c Heal Ser <br /> PP _ r -Envlronmen-taf"Hea3th Perm3 /Services 4. .Ad <br /> 445 N San„Joaquin, P•,O,Box\2009, Stkn, CA 95201 / `✓' <br /> FEEDUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO <br /> AMOUNT <br /> INFO -CASH <br /> . Eli 13.24(REV.rrnel ”"+_ ` �'�`� <br /> EH 14.16 <br /> h <br />