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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 Ho. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />Job Address _ �y �4f Citx,/ /U Lot Size/Acr I& <br />Owner's Name _5002A Address e Phone <br />Contractor <br />Address <br />License No4a'i_ Phone <br />TYPE Of WELL/PUMP: NEW WELL 71 WELL REPLACEMENT F DESTRUCTION Ll Out of Service Well ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR .Cl OTHER ❑ Monitoring Well ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />Ll Industrial <br />Ca Domestic/ Private <br />FI Public <br />I I Irrigation <br />Repair Work Done L7 <br />Well Destruction ❑ <br />TYPF OF WFI I <br />❑ Open Bottom <br />❑ Gravel Pack <br />C] Other <br />— Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />❑ Manteca <br />Pia. of Well Excavation Dia. of Welt Casing <br />❑ Tracy <br />Type of Casing_. Specifications <br />fl Delta <br />Depth of Grout Seal Type of Grout <br />I I Eastern Surface Seal Installed by <br />H. P. State Work Done <br />Sealing Material & Depth <br />Filler Material & Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ! I <br />REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is <br />AMOUNT REMITTED CK <br />RECEIV D BY <br />available within 200 feet.) <br />PERMIT'NO. <br />Installation will serve: Residence _ Commercial <br />Number of living units: __ ._ Number of bedrooms <br />_ Other <br />~ <br />Character of soil to a depth of 3 feet: <br />Water table depth <br />l;/3 <br />SEPTIC TANK. 0 Type/Mfg <br />Capacity No.`Compartments <br />PKG. TREATMENT PLT. ❑ <br />Method of Disposal <br />Distance to nearest: • <br />Well Foundation Property Line <br />LEACHING LINE No. & Length of lines <br />°' Total length/size <br />FILTER BED Distance to nearest: <br />Well Foundation Properly Line <br />SEEPAGE PITS l I Depth of "7— Size !VY a Number <br />SUMPS W-bistance to nearest: <br />Well Foundation Property Lina /fir <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 cenifies 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 California." <br />The applicant must call for a reqed iinnrctions. Complete drawing on reverse side. <br />Signed X- _ J�c�-4 Title: a Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by Date <br />Pit or Grout Inspection by Date Final Inspection by Date <br />L7`i3 s/ <br />�I <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 />EH 13:24 IREV. i / n 5 <br />EH li•2a <br />IFFO <br />AMOUNT DUE <br />AMOUNT REMITTED CK <br />RECEIV D BY <br />DATE <br />PERMIT'NO. <br />/ <br />11`7 <br />Q� <br />