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i <br /> SAN JOAQUIN COUNTY-PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ,I 445 N SAN JOAQUIN, PHONE (209)468-3420 iN O W <br /> P O BOX 2009, .ISTOCKTON, CA 95201 <br /> PERMIT EXPIRES 11YEAR FROM DATE ISSUED <br /> (Complete.11 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 gw�itsh�t3an Joaquin County �rdinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Si , t — <br /> � / City Lot Size/Acreage 7 <br /> Job Address / � q , <br /> Owner's Name <br /> Address I 4 Phons� � d_/ <br /> Contractor s Address License No. Phone <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o out of Service well L3 <br /> h Monitoring Well C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i [=7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> Il Public C7 Other (71 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .--.� Approx. Depth I I Eastern Surface Sedi installed by <br /> Repair Work Done 0 Type of Pump H.P. �! State Work Done <br /> Well Destruction ❑ Well Diameter Sealing.lhlaterial & Aepth <br /> Depth Filler Material & Depth \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION f I DESTRUCTIONavailable within 200feet.)septic system pe}eet.1rmitted if public sewer is <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 /> �i Capacit No. Compartments <br /> f[ SEPTIC TANK. C3 Type/Mfg i Y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well o foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines '� Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> If <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> q 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, and <br /> l rules and regulations of the San Joaquin County I� <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 became subject to workman's <br /> '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 /> Theapplic t must I for al required inspections. Complete drawing�on reverse side. <br /> ignad X Title: Date: 13 I <br /> IM. <br /> Q� R DEPARTMENT USE ONLY <br /> p p -r=.-1^s _. Data 3� Area <br /> k <br /> Application Accepted b <br /> Pit or Grout Inspection by Date ! Final Inspection by Date d w <br /> Additional Comments: <br /> E <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 /> 11 <br /> FEE <br /> NO. <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT <br /> { 1cH 13-24 IREV.t/x SI so rAl, 00 <br /> Eh t4•Ie <br /> r i� � <br />