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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> k4' 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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. <br /> Job Address �� 7 �� ��+ ' City Lot Size/Acreage <br /> �c'h�1 St /L1 Address Phone <br /> Owner's Name <br /> Contractors t � 4 5 .�---Address nse No. Phone <br /> of service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'[ DESTRUCTION ❑ Out Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'] Public fl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LL—BESTRUCTION I I aNailabetic systithinem <br /> rented if public sewer is <br /> Installation will serve: Residence commercial_ Other <br /> Number of living units: —i— 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 <br /> Distance to nearest: Well Foundation / Property Line-- <br /> J�Uf..1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San 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 /> certi' s the following: "t certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's <br /> ." <br /> compensa- <br /> iforr tion l <br /> The <br /> applica t m call for I re fired i pect n . o plate drawing on r rse side. ' ��� <br /> Signe Title: ~�— Date: <br /> 011QARTMENT USE ONLY <br /> Application Accepted by �-^^ Date �--- Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> f � Date d �2 <br /> Additional Comments: <br /> Applicant - Return all copies to: 111ln Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED LA 6 CASH RECEIVED By DATE PERMIT'NO. <br /> INFO <br /> . EH 13.24IREV.1in5r � 17- e,12- 0 <br /> 2 <br /> EH 14.26 -SRF `` , . if,,- S <br />