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38 C) SAN JOAQUIN COUNTY P,UBLIt: HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> . 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> j. <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 i <br /> Joaquin County Public Health Services. <br /> Jab Address City d�Size/Acreage <br /> Owner's Name rh C-uy Address ��t�Y s. Phone <br /> <i <br /> Contractor Address �, N�License N d Phone V074 L <br /> TYPE OF WELL/PUMP: A1; NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION CI Out of Service Well Cl <br /> PUINP INSTALLATION';*- SYSTEM REPAIR Cl OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES X DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l <br /> n Industrial ❑ Open-Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I4 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'1 Public �,� 11 Other,f, n Delta Depth of Grout Seal Type of Grout <br /> I I IrrigationZ, <br /> —.;Approx. Depth I I Eastern Surface Seal Installed by �h <br /> Repair Work Done Q Type of'Pump c, - H,P. - State Work Done 4 1 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> T Depth Filler Material & Depth <br /> :r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet,I jp <br /> Installation will serve: Residence_ Commercial_ Other tf1 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.. D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> a <br /> LEACHING LINE ❑ No. & Length of tines Total length/size I <br /> FILTER BED C] Distance to nearest. Welt Foundation Property Line <br /> SEEPAGE PITS l I Depth Size I Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0. i <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 cenifies the following: "I certify.,that in'the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manneras to become subject to workman's compensation lacus of California." Contractor's hiring or sub-contracting signature <br /> certifies the foll6wing: "I certify that in the performancepf the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." A-- <br /> The applicant all for all require inspectio Complete drawing on revers / t <br /> Signed X Title: - � � Date: d` <br /> ! . <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by _. Date — t— Area a <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 4y <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0.13ox 2009, Stkn, CA 95201 <br /> r <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> --W <br /> I <br /> a EH 124IREV.F/a5i ! 0� f00 <br /> ��� 1/ZA6Z- .2 <br /> EM 14.4.20 <br /> i <br /> I <br />