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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> } ENVIRONMENTAL HEALTH DIVISION <br /> J 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 /> p 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. i� p <br /> 7 l- jG f" City - Lot Size/Acreage <br /> ob ICddress <br /> Owner's Name dress ` d - Phone <br /> Ad <br />' ,� i� address a License No, <br /> ^w / Phone <br /> Contractor � _ <br /> TYPE Of WELL/PUMP: NE4 WELLX WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 Monitor Well L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.OWA-0 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA­ -CONSTRUCTION-SPECIFICATIONS ff <br /> C7 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br />! Domestic/Private XGravei'Pack,`,I.. ,0_Tracy w Type..of Casing-- _ f ".j; Specifications 'r� <br /> T'I 1-1 Delta Depth of Grout Seal type of Grout <br /> Public (-1 Other gqt <br /> 11 Irrigation Approx.-Depth I I Eastern Nace Seal Installed by <br /> Repair Work Done LJ Type of Pump r '` H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth ' <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I t INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r <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. ❑ Type/Mfg Capacity No. Compartments <br /> f PKG. TREATMENT PLT. b f Method of Disposal z <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED [_l Distance to nearest: Well Foundation Property Line: <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation `Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cavity 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 1 <br /> Home owner or licensed agent's signature certifies the following;�'I;certify that in.thte 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 compensati6n laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I canify 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 California." <br /> The applicant rr u affrfoY Lr 'wired Ps or lot on reverse side. <br /> I � Z �- r � Ti[le''` .� Date: <br /> Signed X <br /> 'FOR DEPARTMENT-USE 0 <br /> 71 <br /> Application Accepted by lDate 9 Area d <br /> I Pit r Grau apection by Date """-Final Inspection by ff. Date <br /> /•t wN <br /> Additional Comments: <br /> .�.,.-R—. <br /> �-�. ­­A 3p lie ELnt—Return—ti-k1—ddp-re's'`t o:—San Joaquin County'Publi-e 'Health'Servicesi <br /> Environmental Health Permit/Services <br /> 945 N San Joaquin, P O Box 2009„Stkn, CA.95201 <br /> FEEAMOVNT DUE AMOUNT fiEMITTED CK' RECEIVED BY DATE �PERMIT'NO. <br /> INFO GASH <br /> EH 53-24 IREV.1/M51 f�� ( .�a� �. —Jr C �I <br /> h To <br /> ELZ <br /> EH 14•2a 111 <br /> _ r <br /> f <br />