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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 O 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 Sery ces. _ ` <br /> Job Address 4ye, Cit /p Size/Acreage 2 eZ <br /> Owner's Name �++ Address Phone <br /> Contractor fl. Q <br /> �ddress �oJ License No �*37 Phone 6� s L <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 CDNS*RUCTION'SPECIFICATID . -IN <br /> I�1 Ind al ❑,, Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin [ J <br /> C. omestic/Private Ili- ravel Pack ❑ Tracy Type of Casing_ G ^specifications V <br /> I'1 Public I'1 Other (l Delta Dept-9f Grout Seal a0�-- Jype'of Grout r <br /> I i Irrigation Approx. Depth I astern Surface Seal Installed7by C°d I.AA l✓ <br /> Repair Work Done *../_ Type of Pump H.P. '" T a St irk Don <br /> W <br /> Well Destruction Well Diameter "cling Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REP IS(ADDITION i I DESTRUCTION 11 (No septic system permitted it public sewer is <br /> available within 200 feet. <br /> Installation will serve: Residence___... Commercial T Other <br /> Number of living units: NumberroomsZ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/MfgyZFn,'1,u,- <br /> Cap ty No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Welt Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED C;1 Distance to nearest: Well Foundati Property Line <br /> SEEPAGE PITS 11 Depth Size ber <br /> SUMPS Ll Distance itnears . Well Foundation Properly Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this plication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner o►liQcarfifV <br /> gnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shelf not <br /> employ any perso as to becoms subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the foil t in the performance of ork for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of lifxee.The applican muired s re i <br /> Signed X Title: r Date: M--az/ � <br /> 47 <br /> FOR DEPARTMENT USE ONLY <br /> ^1J� <br /> Application Accepted by Dale Area r <br /> Pit or rout napection by fec- Date i nal inspection by Date <br /> Additional Comments: f r Q "" �� <br /> 41 <br /> Applicant - Return all copies to: San Joaqui County Public Health Services DU�h¢� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 952011 <br /> INFO CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> + J� <br /> EH 13-24(REV.i/n51 �� A-P2 <br /> EH 14.26 1 6 *Q f0 10 <br /> 0 <br />