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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, STOC%TON, CA 95201 � �, <br /> PERMIT EXPIRES 1 YEAR FROM DATEfISSUED <br /> (Complete in Triplicate) 0 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein ddescr ed. 64j <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 /> w <br /> 'x o r Job Address 7 CityS 0` Lot Size/Acreage <br /> I �(\Owner'a Name G `� ea eddress `�� A " a R - PhoneW �T <br /> /xConlractof Address y O License ND. Phone 7" <br /> TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT n DESTRUCTION o out of Service Nell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial _ O Open Bottom ❑.Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> [:1 <br /> Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications <br /> I'1 Public [I Other n Delta Depth of Grout Seal <br /> Type-of Gout <br /> r I.i Irrigation Approx. Depth I I Eastern Surface Seal Installed by[ <br /> Repair Work Done 0 Type of Pump H.P. Sti§ <br /> ne Work Done_. <br /> Weil Destruction ❑ Well Diameter ' <br /> Sealing Material & Depth 1 <br /> Depth Filler Material & Depth f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDiTION IAi -.DESTRUCTION No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> f <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: — 4 Water labia' depth 1 <br /> SEPTIC TANK- ❑ Type/Mfg <br /> Capacity No. Compartments f <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest; Amell-- Foundation - Property Line i <br /> LEACHING LINE ❑ No. & Lengfh of`lines L Total lengthlsiie <br /> FILTER BED 0 Distance to nearest: Wall Foundation Property Line l <br /> F SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well $ Foundation ' _P_roperty..Line_ <br /> DISPOSAL PONDS ❑ <br /> t; I hereby certify that 1 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 /> f 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 shall not <br /> F 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 ust call for all required ihs " ions.-Com te-drawing on reverse side.— <br /> �( Signed X2YjtfCA91& Title: f/lj P R t Date: <br /> � r <br /> OR DEPARTMENT USE'ONlY - <br /> Application Accepted by �" Data —I= I Z Area � <br /> I Pit.or Grout Inspection by Date Final Inspection by �X1?2 1 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 O Box 2009, Stkn, CA 95201 <br /> f <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY {SATE PERMIT'NO. <br /> INFO CASK <br /> toe <br /> . Eh 13-24 IREV.UAS) //y/ <br /> EH 14.26 r <br />