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-) r0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> `--1ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT F.gPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby tsade,to Sap Joaquin County for a permit to construct and/or install the work herein described. This <br /> applicatlon is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. y� <br /> Job Address IJ �- Aa`r City` Lot Size/Acreage <br /> Ij <br /> Owner's Nam Address ftJ7 rF --22 � 1 <br /> Phone <br /> Contract r�(CJOI> Address ` �` a <br /> i � License No­l Z y Z z �- Phone 14' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> C7 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing-- Specifications <br /> 1.i Public (-I Other n Delta Depth of Grout Sealk J <br /> Type of Grout <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done [.J T <br /> ype of Pump N.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I IREPAI ADDITION 7< DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: —�— Number rooms <br /> Character of soil to a depth of 3 feet:r �- <br /> Water table depth - <br /> SEPTIC TANK ❑ Type/Mfg Capacity. 116two No. Compartments 2— <br /> PKG. TREATMENT PLT, O <br /> Method of Disposal <br /> Distance to nearest: Well Foundation: Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance to nearest: Well ie '14- Foundation_ /(J + <br /> DISPOSAL PONDS ❑ Property Line <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 /> 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 issueI shall not <br /> d, { <br /> employ any person in such manner as to became subject to workman's compensation laws of Caiifomia." 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 call for rgpuir d insPections. Complete drawing on reverse s' e <br /> Signed ff � .�'L - <br /> Title: Date: �^^ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by J <br /> // Date` (}� r Area Z <br /> Pit or ro Inapectian by Date L Final Inspection by <br /> C��_ Date <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 0 Box 2009, Stkn, CA 95201 V�Y <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY <br /> /J y/ CASH /// DATE Q PERMIT'NO. <br /> . EH 13-21)REV.iiMs /�(• ! / /�� //" /,�-�� �Le V ­1 ���Ir! Z ��r �� <br /> EH 11-� - ( 6 <br />