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w� 4 <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 /> 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. / - w 1_ <br /> City �"^"'-'Wh - --nLot SiSize/Acreage X_ ,} <br /> job Address <br /> 6 Address .Tg�7--s-"-- Phone <br /> Ci A <br /> Owner's Name � �I <br /> Contractor dress <br /> (� G License NoZ73 Phone d- <br /> TYPE OF WELL/PUMP: NEW L ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well 7 <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 <br /> OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSDia. of W4II Casing <br /> D Industrial ❑ Open Bottom C7 Manteca Dia. of Well Excavation <br /> • •"` Specifications <br /> C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ — <br /> I'I Public <br /> 1-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ..Approx. Depth l I Eastern Surface Se Installed by <br /> H.P. State Work Done <br /> Repair Work Done 13 Type of Pump <br /> Sealing Material le Depth <br /> Well Destruction ❑ Welt Diameter Filler Material 6 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAL REPAIRlADDITION i I DESTRUCTION I I availablewithin2OOp emitted if public sewer is- <br /> TYPE <br /> installation will serve: Residence A- Commercial 3 Other <br /> Number of living units: Number of bedrooms # <br /> Water table depth 12215 <br /> Character of soil to a depth of 3 feet: ~ <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity-LL - No. Comptartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Property Lindi�� <br /> LEACHING LINE ❑ NVo� Lee gtth of lin / Total length/s ze <br /> FILTER BED ( Oi3far�c�t86are"si:�� ell- — Foundation ,s Property Lina _ <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state law„ end <br /> 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." <br /> The applicant must call for all requi ed ' 0e.clions. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> R EPARTMENT USE ONLY <br /> Application Accepted by <br /> Date - �Af _ <br /> Pit or Grout Inspection by Date Final inspection by Data��� <br /> Additional Commence: <br /> I , James Hancock, Owner of 8899 Endow R verify that sep 1c ystem <br /> was fns a e as s own On perms cxyy�o.t M <br /> Applicant - Return all copies to: San Joaquin County Public Health Service-d- <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDw9g!Ho <br /> PERMET'NO. <br /> INFO fH13.2�iREV.�iHs��w� �� � / <br /> EH to-te 1 <br />