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• AL <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> Pe <br /> >; P 0 BOX 20097 STOCKTON, CA 95201 <br /> o PERMIT E%PIRES ]. YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> App11c is hereby made to Sou Joaquin Gounty for rmit to construct and/or install the cork herein described. This <br /> a cation ie made in compliance with San Joaquin County nce No. 51+9 and 1862 and thefRules and Regulations of San <br /> uia Count Public Health Services. �• <br /> � 5 <br /> Job Address "' �� • � Lot Size/Acreitg�.._ <br /> Own a Address 96:3v 4phone <br /> Contractor ��� Address License tufo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'S OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O <br /> n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing <br /> f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications L <br /> I'1 Public 1-1 Other 1`7 Delta Depth of Grout Seal Type of Grout G <br /> Irrigation -_._Approx. D.pt I ItEastern SSeal Installed by <br /> Repair Work Done Type of Pump - � um H.P, State Work <br /> Well Destruction ❑ Well Diameter Sealing Materiel & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 feat.l <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Z <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size (� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 e <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; "I certify that in the performance of the work for which this permit is issued, I shall nor <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' compensa- <br /> tion laws of C <br /> Thea ant mus call for all required ' spections. Complete drawing on a arse side. <br /> Signed Title: _ F�S Date: �� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Z Area 1 <br /> Pit or Grout Inspection by Date Final Inspection by Data <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 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. <br /> INFO RFI_ <br /> EH 13.2!IfIEV.s i w i ��� !�[ ,� "Z y <br /> EH s1-2e JJJ ` ✓f! <br />