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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. J f� 1 <br /> a [ I�Q City����- Lot Size/Acreage <br /> Job Address <br /> e tti �/I G _ ddr �a-+ Phone =� <br /> Owner's Name Address <br /> Ua �� SJR I r " Address t 'v ' /� License No.O�gg38-_Phone �� <br /> Contractor - <br /> TYFE OF_WELL/PUMP: _ <br /> NEW WELL ❑ WELL REPLACEMENT DESTRUCTION`AOut of Service well ❑ <br /> PUMP INSTALLATIONA SYSTEM REPAIR ❑ OTHER ❑ <br /> Monitorie�j3 well- U <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 /> M Industrial )9 Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications —�--� <br /> Domestic I Private ❑ Gravel Pack ❑ Tracy , G3 �l <br /> Cl Public I.] Other f 1 Delta Depth of Grout Seal Type o tout -- <br /> �ll-I K'= <br /> I I Irrigation 3©� Approx. Depth I I Eastern Surface Seal Installed by r <br /> Repair Work Done ❑ Type of Pump H.P. tate k Done U( <br /> Sealing Material & Depth ..5 <br /> Well Destruction >,I- Weil: Diameter <br /> Filler Material & Depth <br /> Depth � <br /> TYPE OF'SEPTIC'WORK,—NEW'INSTA-VL TION�l I—HFPAiR-IADOtTION-t-1" DESTRUCTION-1-t-11Vo-septix`spsl'efr+ pe'mitted it 0151;2 server is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to s depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line N1y <br /> No. & Length of lines <br /> LEACHING LINE L-1No. length/size g �.r <br /> FILTER BED f7 Distance to nearest: Well Foundation Property Line <br /> ' <br /> SEEPAGE PITS 11 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 taws, 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 California."the work for is which this permit is issued, I shall not <br /> employ any person in such manner as to becomersubject to workman's compensation laws of ed, shallContractor's hiring c subcontracting signature <br /> candies.the following: "I certify that in the perfoSmence 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 must call f r all required ins ctions. CoAhplete drawing on reverse side. <br /> Signe Title: <br /> GGr 5, Date: 3 <br /> IR EP RTMENT USE ONLY y <br /> Application Accepted by <br /> _ Date ���'\�s- l �-�- Area <br /> Pit or Inspection by Date Final Inspection by 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 0 Box 2009, Stkn, CA 95201 <br /> F <br /> FEE <br /> ' INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ATE gPERMIT'NOigEH 13-4 IrIEV.3/X 51 <br /> EH 14.2E � <br />