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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> f�21 0 P 0 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 2862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address x City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contractor �`L Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl 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 /> Gl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done v Type of Pump H.P. State Work Done <br /> Well Destruction [3Well Diameter Sealing Material 8 Depth <br /> Depth Filler Material S Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 470DESTRUCTIONI I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence v Commercial_ Other f <br /> Number of living units: _Z_ Number of bedrooms _ I <br /> Character of soil to a depth of 3 feet: --V A7^ Q y e 4!i4}'Y __ Water table depth 1 <br /> SEPTIC TANK (Y Type/Mfg �I s L aer1 e=6e-_'Capacity x000 No. Compartments Z <br /> PKG. TREATMENT PLT. ❑ / .0Method of Dispcjsal <br /> Distance to nearest: Well `r Foundation 3f Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BEQ W—'Distance to nearest: Well Foundation � Property Line b <br /> _ !"44 �z4° a,, re-r 6e_p w.•Ttr, ez �ne-k. u#I ��r ��pex <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not T <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 compansa- <br /> tion laws of California." <br /> The applican m call for all req inspection C plate drawing on reverse side. <br /> i - <br /> Signed Y Af ITitle: „X C'] t.� ir1 �-r Date: <br /> F DEP MENT SE Oy1Y <br /> Application Accepted by Date Area �� <br /> Pit or Grout inspection by Date Final Inspection Date" <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 REMITTEDH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EM 13-24tR1V.i/nSi - // • OQ _ / f �-� �� / /�� <br /> EH 14.26 <br />