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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> t <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,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. /f �7" <br /> Job Address y U h FCity _CffLfo Size/Acreage , <br /> Owner's Name Address - _— Phone <br /> • fot19 7 <br /> Contractor2&- Address ense No. Phone <br /> , 4 �tz"_1=" <br /> TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT F1 DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well <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 /> L7 Industrial ❑ Open Bottom r ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.l Domestic I Private D Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Il Public' M Other n Delta Depth of Grout Seal Type of Grout X l <br /> I I irrigation — Approx. Depth I I Eastern Surface Seai Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done t <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION K DESTRUCTION I I INo septic system permitted if public sewer is <br /> L <br /> available within 200 feet.) <br /> Installation will serve: Residence f_ Commercial ,,,Y.. Other <br /> Number of living units: _..I_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg fz-4 - __ Capackyl ID0 _ No. Compartments V <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation d Property Line <br /> LEACHING LINE ❑ No. $ Length of,lines Total length/size ton <br /> FILTER BED ❑ Distance to nearest: Well 9- Foundation ._�_ Property Line <br /> SEEPAGE PITS 11 Depth A ISize Number <br /> UMP Ll Distance to nearest: Well �>7d m Foundation J Property Line B D <br /> ISPOSAL PONDS ❑ <br /> I hereby certify that 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: "t 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 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 taws of California." <br /> The applicant must call for all r ire inspections. Co to drawing on reverse side. f r <br /> Signed Title: 4 A� Date: <br /> t <br /> %F=PAIRTMENT USE ONLYApplication Accepted by � �-- - '�- Date Z Area Q S < <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 O Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO / <br /> y <br /> � <br /> + EK 13-24IREV.fiK51 <br /> EH t4-25 <br /> i <br />