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ti <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 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 <br /> /Public Health Services. P44 ^t-,� Q( <br /> Job Address I `/SIy " RUTH`, � City M`C Lot Size/Acreage " , CkS <br /> Owner's Name NN ' i'Ilel"©'j Address S PC Phone <br /> Contractor ) f 22 A"AR—Address / !50 �� ��eLicense No. �p _Phone �2� ��� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL-:REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ 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 O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public 1:1 Other i-1 Delta Depth of Grout Seal Type of Grout t <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 i <br /> Well Destruction O Well Diameter Sealing Material & Depth -- <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION (r DESTRUCTION 1t. Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Reside ce Z Commercial Other <br /> Number of living units: Number ofkedrooms <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. 0 <br /> 5 , S t Method oto osal <br /> Distance to nearest: Well Foundation Property Line arc <br /> LEACHING LINE Cr-No. & Length of lines Total length/size ` <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I.1'--Depth Size _ Number f <br /> SUMPS LI Distance to nearest: Well J, Foundation g t Property-Line 6c� <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 baso subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the pe mance 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 m all for all r ins ions. Complete drawing on re arse side. r <br /> Signed Title: Date: �� `7 <br /> FOR DEPARTMENT USE ONLY <br /> O <br /> Application Accepted byDate <br /> Pit or Grout Inspection by Date 1 Final Inspection by Dated <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaga_.. County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. <br /> INFO / {� QJ <br /> EH 13.21(REV. < <br /> r <br /> EH 14 1 '.26 '� <br />