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i <br /> SAN JOAQUIN COUNT,Y 'PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL H *LTH DIVISION <br /> 445NSAN <br /> JOAQUIN, PHONE 2009, STOCKTON, CA)95201420 <br /> POOX <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j� (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 /> C <br /> Job Address C7 ` �/r City Lot Size/Acreage <br /> C <br /> Owner's Name 6 c Zg✓�yG- Address t4 hone <br /> Contracto �YAddress ,, �- ��eLicense N�_, 2;�!,�- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of service Well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well �7 <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 O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth A I Eastern Surface Seal Installed by <br /> Repair Work Done YCJ Type of Pump H.P. 1 State Work Don <br /> Well Destruction O - Well Diameter Sealing Material & Depth ` <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> t. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI 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 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 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: " 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 C ' rnla." <br /> The applicant must call r all required ins tions. mplete drawing on revs e s' e. <br /> Signed X Title: Date: _f/55:71 <br /> �FO DEPARTMENT USE ONLY /1 <br /> Application Accepted by �� -- - \\\\yy�� °�` Date _` ZArea 0 7_1 <br /> Pit or Grout Inspection by Date Final Inspection by Date lb <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 9ATE PERMIT'NO. <br /> INFO <br /> . EH14.21 IREV.dear <br /> EH 11.26 <br /> 111 � <br />