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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQU IN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 RECE-:1 veD <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fP ' � <br /> (Complete in Triplicate) 3 1992 . <br /> SRN JQAC(li I I <br /> Application Is hereby made,to San Joaquin County for a permit to construct and/or install the vork!� ereirm F sc the his <br /> application is made in compliance with San J quip Count Ordinance o. 549 and 1862 and the �2iu1'es�aad Rye tilat-b <br /> Joaquin County Public Health Services. tc oQQ $', Al �� HL AO}i 0!V1$J0rq <br /> City Lot Size/Acreage <br /> Job Address t <br /> t <br /> G. Address Phone <br /> Owner's Name ` / <br /> Contractor <br /> Address 1 License No. �� Phat+ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION i� SYSTEM REPAIR D <br /> OTHER O Monitoring Well L7 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE o --TYPE OF WELL— PROBLEM AREA CONSTRUCTIONSPECIFICATIONS <br /> i Dia. of Well Casing <br /> L� Industria! ❑ Open Bottom C� Manteca Dia. of Well Excavation Specifications• <br /> fl <br /> Domestic/Private Gravel Pack L7 Tracy Type of Casing_. <br /> I'! Pt lic <br /> [.1 gIher f-1 Delta Depth of Grout Seal Type of Grout <br /> rriUation .Appro><. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump � H.P. State Work Done 1 ILf <br /> Sealing Material & Depth (�l <br /> Well Destruction ❑ Wel! Diameter Filler Material & Depth <br /> Depth 2 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDiTION I i DESTRUCTION I ! INo availablerwithin 200 feesystem t.1 ed i1 public sower Is ` <br /> d <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SE'.-&TANK ❑ Type/Mfg Capacity No. CompartmentsPTI <br /> W <br /> Method of Disposal <br /> PKG. TREATMENT PLT, 0 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> I e <br /> j SEEPAGE PITS 11 Depth Size Number <br /> I[ SUMPS L! Distance to nearest: Well Foundation Property Line <br /> _ DISPOSAL PONDS 0 ordance with San Joaquin county ordinances, statelaws, and <br /> I hereby certify that I have prepared this application and that the work will be done in acc <br /> rulesand ragulat, ns of the San Joaquin County <br /> Home owner o l' ensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall not <br /> employ any n in such manner as to me subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f ing: " 'fy that in the rlormence of the work for which his p it is iscued, I shall employ persons subject to workman's compensa- <br /> tion laws of I or <br /> fThe ap lice t ust all f al req i peciions. Complete drawing on r ver ide. <br /> Signed <br /> Title: Date: tel/ <br /> FOR DEPARTMENT USE ONLY I <br /> i Application Accepted by <br /> Date � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> �- <br /> k f <br /> Additional Comments: <br /> fl Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, . 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> AMDUNT DUE AMOUNT REMITTED �KLyRECEIVER BY DATE PERMIT'NDEH 13-24 iREV.t ins) <br /> :INFO <br /> J']� Qf� &L) <br /> �� ` r <br /> EH 14.26 <br />