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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> \ ENVIRONMENTAL HEALTH DIVISION <br /> �h 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 4P(__ n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1" (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 1n 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 5MC it i ©C5F-K-CityLot Size/Acreage <br /> Owner's Name( /`y P �� ✓ 6 v Address s�-�- P Phone <br /> P <br /> ContractoA,k.- .� Addres�r /L'/ �►1 tee. a L!'2dl License No.,- <br /> /e? PhoneV4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR X OTHER O Monitoring Well <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 /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'l Public EI Other n Delta Depth of Grout Seal Type of Grout <br /> I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Ur Type of Pump H.H.P. 2 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 /> 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 /> 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 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: "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 C <br /> The cant must all for all required i pectns C <br /> ioomplete drawing on revs siid/a.. <br /> Signed X Title: �(� S Date: <br /> FOR <br /> DEPARTMENT USE ONLYZ►- <br /> Application Accepted by ��ti►��•�� Date_ _ Area ©Z� <br /> Pit or Grout Inspection by Date Final Inspection by Date X14 22- <br /> Additional <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 <br /> tFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVNO. <br /> on I <br /> . EH 13-21 IREV.tie 51 . / 9,/ /� g <br /> EH 11.26 ll k2-3 <br />