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xt•YLil.A1iV1t1HN.�(�A •_'0'W"_PLIC HEALTH SERVICES <br /> SAN AQUIN COUNTY PUBLIC HEALTH "�f DIVISION <br /> ENVIRONMENTAL HEALTH DIVISI.r-.>i .-�, PERMIT <br /> 445 N SAN dOAQUIN, PHONE (209)468-34 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES .1 YEAR FROM DATE ISSUED I <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. 569 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address — _ 7 a 5: 10• _LA_r\; nn City 5"1oc- Lot Size/Acreage <br /> Owner's Name cnn �L� Ca• Address :� a5'/V o, Phone <br /> Contractors b i 5rew�c2,Z..s.AddressQ-7`1 I 121 License No. 9I/�-670 Phone C 537_57` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ i <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well j <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 /> Cl Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation /J2V o.gL Dia. of Well Casing y <br /> I <br /> C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casings c1.c-4,fe-__�/O Specifications j <br /> I'1 Public Cl Other n Delta Depth of Grout Seal y�' Type of Grout c <br /> I i Irrigation Z'Approx, Depth I I Eastern Surface Seal Installed by OtSerbcr� Tc.ayT�Tr�C� <br /> Repair Work Done 17 Type of Pump H.P. State Work Done <br /> Weil Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRtADDtTION I L DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> available within 200 feet.) <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.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines I Total length/size <br /> FILTER BED 0 Distance to nearest; Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property fine <br /> DISPOSAL 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, an <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 issu , 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 /> The applicant m r all required inspections. Complete drawing on r rse side <br /> call fo . I <br /> Signed , Title' "" _ Date: ✓ f �,� ��41 _ <br /> 1 <br /> FENT USE ONLY i <br /> Application Accepted by Date. . Area <br /> Pit or Grout Inspection by Date �� Final inspection by Date <br /> Additional Comments: <br /> f <br /> Applicant - Return all copies to: San oaquin County Public Health Services y <br /> Environmental Health Permit/Services ��y©� <br /> 445 N San Joaquin, P 0 Baa 2009, Stkn, CA 95201 <br /> CK d <br /> FEE <br /> INFO AMOUNT DUE AMODUN`T REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . EH13-24(REV.IIn51 !K 7�"1 IH551 <br /> EH 14-29 <br />