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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> " ENVIRONIMTAL-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 /> Job Address rl� fl/4� �i1 �_ City /t 4 Lot Size/Acreage a 4 <br /> �� l <br /> Owner's Name Address Phone <br /> t <br /> C.ontractoer Address License' Phone <br /> TYPE OF WELLIPUMP: NEW WELL'❑ WELL REPLACEMENT ❑ DE TRUCTION D Out of Service Well Cl <br /> PUMP iNSTALLATION ❑ SYSTEM REPAIR M OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROM 1@[jIl§�P(7g,®■�� TQ SERVICES f <br /> C� industrial ❑ Open Bottom ❑ Manteca E,NVI�C@��r[YT�,S�r!•"%11g�T'TT7 s�7crinr�+�r Dia. of Well Casing <br /> ' [a Domestic/Private ❑ Gravel Pack ❑ Tracy Sia Specifications <br /> f i"1 Public to DtFier` fl Datta J Type of Grout �) <br />,F 1 I Irrigation .____..Approx. Depth l I Eastern Surface Seal Installed by s <br />!` _ a <br /> Repair Work Done ❑ Type of Pump H.P. State,Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material & Depth <br /> E Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION (No septic system permilted it public sewer is <br /> s / availabie within 200 feet.) <br /> r inatatlation will serve: Re rdence Commercial_ Other r <br /> y � r - . <br /> Number of living units: 17 Number of bedrooms ` r`f i <br /> 7 Character of soil-to a depth of 3 feet: Water table depth <br /> s SEPTIC TANK ❑ Type/Mfg A Capacity No. Compartments <br /> PKG. TREATMENT,PLT. C1 .� Method of Disposal <br /> Distance to nearest: ell '''` Foundation Property Line <br /> rt <br /> ` LEACHING LINE No. & Length-of lines '' Total length/size— <br /> ion <br /> 's FILTER BED C1 Distance to nearest, ell ' FoundatProperty Line? <br /> SEEPAGE PITS Depth n: -Size oNumber <br /> SUMPS F 1 Distance to nearest: Well, oundation Property Lin <br /> Fe <br /> DISPOSAL PONDS ❑ ''n • <br /> I hereby certify that I have prepared this'appiication 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 shah not : <br /> ernploy any person in such nner-as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ,certifies the following: "I cert in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> non Caws of California." <br /> Thea II r a required pections. Complete drawing on raver side. <br /> Signed X <br /> Title: Date: <br /> s" f <br /> :. FOR DEPARTMENT USE ONLY <br /> Application Accepted by i t r Date 7� Area r r <br /> Pit of Grout Inspection by Date. Final Inspection by ' DateZ 4z; y �� <br /> ell, 1 <br /> Additional Comments: Ate-Ke i ro r -j�� �q/�� f 1�y`�.`�� <br /> Applicant - Ret n 0 -copies o: San aqu n Oodnty ublicc eH altheS ry ces �-ku J rftF4A4�, f � <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin_ P O Box_2009.,_Stkn,.CA-95201_. .- <br /> T FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, <br /> INFO CASHjrr/� <br /> ' f n4 1 �j <br /> a EM 13.24 iREV.t/n 51 S J� t 2 �q� - 7 /'f'Z �/[� <br />