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A PLI,gAI`ION. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> R61-Ile �Q pa c t/~ PERMIT EXP I RES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby rnade,to San Joaquin County for a permit to construct and/ install the work herein described. This A <br /> application is trade in compliance-with San Joaquin County Ordinance No. 549 and 1862a.nd the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address C City y Lot Size/Acreage <br /> Owner's Name . !►r �P q� r Q rl t'7 Address sc�. Phone <br /> Contractor &L,clo z4 C_ Addressf- 7 icense No. cMC✓ Phone 'r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [D , DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic]Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> f'1 Public fa Other r f-1 Delta Depth of Grout Seal Type of Grout { <br /> r�Y IrriUation Approx. D2ptb_ I I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump �� _ �H,P, V� State Work Done ` <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> i <br /> Depth Filler-'Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR%ADDITION i I DESTRUCTION I I (No septic Systam,perrnitted if public sewer is i <br /> availablebW'ifhin 200 feet:l\ i <br /> Installation will serve: Residence_ Commercial-�„�Other_ <br /> Number of living units: Number of bedrooms A. <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. ❑ K l`�.'Method of Disposal <br /> Distance to nearest: Well Foundation Property Line F <br /> r� <br /> � w <br /> LEACHING.CINE 'CI No. & Length of-lines Total length/size <br /> FILTER BED f"rl Distance to nearest: Well.-; Foundation Property Linet4 ? <br /> SEEPAGE PITS 1,Depth� Size Number. <br /> SUMPS Ut Distance to nearest: Well .Foundation -.... Property Line <br /> DISPOSAL PONDS w ©^ _- ' ° rr <br /> I hereby certify that I have prepared this application and that tlie,wo'rk will•bi done in accordance with1Sah 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 <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's compensa- <br /> tion laws of California." <br /> "i <br /> The appli must for all required i pection Complete drawing an rev se de. <br /> SignedX Title: Date: - <br /> F DEPARTMENT USE ONLY <br /> 0& <br /> Application Accepted by �- ��+ Date Ar <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 So 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK III RECEIVED BY DATE PERMiT'NO. <br /> INFO .�f� q `r <br /> . EH13-241REV.r/x5 Si ��/ ?Loq <br /> 1���4tJ <br /> EH 1 .20 <br />