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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1445 N SAN JOAQUIN, PHONE {209}468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San 1[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. �/� <br /> CitysixdY lot Size/AcreageI�CJK S <br /> Job Address _�� <br /> f ` i <br /> (Tl <br /> Owner's Name Phone <br /> Address � _ <br /> _Contractor ddres,P _a' �1` �' � License No, Phone <br /> TYPE OF WE NEW VVELL WELL REPLACEMENT-❑""�"""" t <br /> DESTRUCTtON-C-Ou -of-Servi-ce-Well—G3 <br /> PUMP INSTALLATION Jr� SYSTEM REPAIR I-] OTHER C3Monito iWell U <br /> F4 co <br /> DISTANCE TO NEAREST: SEPTIC TANK /00 - SEWER LINES D15POSAL FLD. PROP. LIN <br /> 71 MO <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTIOWSPECIFICATIONS <br /> D Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing__., ,� — Specifications <br /> I'1 Public i l Other f l Delta Depth of Grout Seal a Te of Grou <br /> TypepjJ <br /> r tX LAY Drol 11 nn <br /> 11 Irrigation ..Approx"De�pth"�L�,I I Easternurfac_e Seal installed g stby <br /> Repair Work Done L7 Type of Pump ..psi H.P. State Work Dane, <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth II Filler Material & Depth v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is <br /> available within 200 feet.l r <br /> Installation will serve: Residence Commercial— Other <br /> + Number of living units: Number of bedrooms <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 . r <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line <br /> I <br /> SEEPAGE PITSI I Depth 'N Size Number <br /> SUMPS L! Distance to nearest: Well Foundation Property Line <br /> " b { <br /> DISPOSAL PONDS 0. , l`. <br /> I hereby certify that I have prepared thiel application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> i rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies 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." III <br /> The applicant must call for all requ red inspections. Complete drawing on reverse side. <br /> Signe i � Title: ' Date., I <br /> FQ DEPARTMENT USE ONLY. <br /> t Application Accepted by I Date �' Area P <br /> x Pit or rout nspection by Date- Final Inspection by Date 4 <br /> Additional Comments: <br /> i w <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 FEE <br /> INFO AMOUNT DUE�� AMOUNT REMITTED^ CASH `RECEIVED BY—'r ""PATE'`— "PERMIT NO ' <br /> LU 01 <br /> 2 9� <br /> + EN 13.241 REV,1/M 51 <br /> EH 1446 am <br />