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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address <br /> Owner's Name Address t Phone1,U--3_20__ <br /> i <br /> r I <br /> Contractor ddres <br /> .$ . ! icense No Phon <br /> 467--7-91 <br /> WEL P: NEW WELL ❑ WELL EPLACEMENT n DESTRUCTION 0 Out of Service Well LI <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ElMonitoring Well <br /> Go NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE-2-377 <br /> FOUNDATION rAGRICULTURE WELL' OTHER WELL _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATi_QfJS " V <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> public Cl Other n Delta Depth of Grout Seal Type of Grout v yl <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Sedi installed by ti <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth <br /> Depth Filler Material A Depth Q <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted it public sewer is n <br /> available within 200 feet.) V <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. 0 Type/Mfg Capacity No. Compartments Is. <br /> PKG. TREATMENT PLT. ❑ ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines µ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS r 1..1 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 <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 Cafifomi <br /> The appii t u all or ai*rred inspections. Complete drawingon #Ierse side <br /> Signed X Tilldi (/,�Ay� � _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date gov <br /> Area <br /> Pit or Grout Inspection by �D/ �o,gat / Final Inspection b Date <br /> Additional Comments: WF k / UAC11 , <br /> F sir � <br /> Applicant - Return all copies to: San Joaquin County Public Health Service <br /> Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . Eli 13.24 iREV.t/K slIJ' + � <br /> i EH 14.26 <br />