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j SAN JOAQUIN COUNTY PT46IC HEALTH SERVICES <br /> 43 U" ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> DP O BOX 2009, STOCKTON, CA 95201 <br /> S,� PERMIT IRE 1 YEAR FROM DATE ISSU <br /> T7� ID <br /> (Complete in Triplicate) <br /> Application is <br /> ounty <br /> rmit <br /> struct <br /> tall <br /> work <br /> in <br /> application n is made n co®pliance withuSanJoaquin County OrdinancenNo. 549aando1862aand theeRules andeRegulationsdof Sans <br /> Joaquin County Public Health Services. <br /> de City Lot Size/Acreage <br /> Job Address•' C <br /> c.Jt7_&4A_ ,� — Phone <br /> Address <br /> Owner's Nam < < <br /> Address <br /> /OLicense No ! Phone <br /> ContractorDESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER O <br /> SEWER LINES _______---- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ._._ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing_ <br /> 0 Tracy <br /> fI'lI'1 Public Cl Other <br /> Domestic/Private ❑ Gravel Pack n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation ._.- Approx. Depth I I Eastern Surface Seal Installed by � <br /> of Pump � CL H. _ State Work Done <br /> Repair Work Done P'' Sealing Sealing Material & Depth <br /> Well Destruction O Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I I DESTRUCTION I I INeilabltic Sy t m feet.) if public sewer is <br /> Installation will serve: Residence_ Commercial Other _ <br /> Number of living units: Number of bedrooms <br /> Water table depth , <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK 0 Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> Property Line <br /> FILTER BED O Distance to nearest: Well Foundation <br /> I I Depth Size Number <br /> SEEPAGE PITS Property Line <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work <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 /> certifies the follow• 21-ur <br /> ertify that in the performance of the work for which this permit is issued, 1 shall,employ persons subject to workman's c pensa- <br /> tion laws o 1 ornla <br /> The icant must all required ins ns. pieta drawing on ver side. <br /> Title: Date:. <br /> Signed <br /> F DEPARTMENT USE ONLY <br /> �. . ._F Date `,l Z Area <br /> Application Accepted by _ <br /> Pit or Grout Inspection by <br /> Date Final Inspection by���"""' <br /> Additional Comments: <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 /> FEE ECASSH <br /> RECEIVED BY DATE PERMIT'N0. <br /> INFO AMOUNT Dt1E AMOUNT REMITTED 4.�r� , o/ <br /> . EH 13.2 (REV.t/n sl <br /> EH 11.25 <br />