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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 1 <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Healt�h Se ices. � <br /> Job Address 7�1� led, Cityr Lot Size/Acreage <br /> Owner's Nsmt„ d �f`' Address Phone <br /> Contract r ddress ►`�� �� I License N6„SZ 9 ZZ•(p Phone C 5 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION C] Out of Service Well 0 <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 CONSTRUCTION SPECIFICATIONS F <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia..of Welt Casing <br /> [I Domestic/Private ❑ Gravel Pack CJ Tracy Type of Casing_ Specifications <br /> t <br /> Il Public CI Other Cl Delta Depth of Grout Seal Type of Grout ” <br /> 1 1 Irritation ­Approx. Depth i I Eastern Surface Seal installed by <br /> Repair Work Done [J Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth ler Material & Depth C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I EPAIR/ DDITIO DESTRUCTION t I (No septic system permitted if public sewer is <br /> available within 206 feet.) <br /> Installation will serve: RasiQence�. Commercial�ther <br /> Number of living units: 1 Number of be rooms <br /> Character of soil to a depth of 3 feet: AJ Water table.depth 6 <br /> SEPTIC TANK CJ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of-Disposal <br /> Distance to nearest: Well Foundation- Property Lina <br /> rr <br /> LEACHING LINE No. & Length of lines Notal length/size t� l <br /> FILTER BED ❑ Distance to nearest: Well-•3'� 4 Foundation O 4 Property Line <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 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 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." E <br /> The appfica ust cal all quired inspections. Complete drawing on reverse side <br /> Signed XTitle: �; Date: <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by Date ! Area <br /> Pit or Grout Inspection by Date Final Inspection by Date�_ �2 - <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 D Box 2009, Stkn, CA 95201 <br /> INFO <br /> AMOUNT DU�E7 AMOUNTREM CASH RECEIVED BY -D/ATeE q PERMIT NO.7 <br /> . EM 13.24IREV.I/Hsi d u / �� T��1 'a-/ D`[ 2- f2�gli <br /> EM 14-Zs !' <br />