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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 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 Ser ces. <br /> Job Address 3 , City Otk) Lot Size/Acreage <br /> n 14 i <br /> Owner's Name Address Phone1.al2jW:�3 <br /> 1�i11 <br /> B�IVo. h I phone + 2 i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT l:) DESTRUCTION ❑ Out of Service" Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM=REPA , DTHER C3Monitoring WellDISTANCE TO NEAREST: SEPTIC TANK SEWER LINESOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> striae ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> mastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'l Public 0 Other F� Delta Depth of Grout Seal Ty p of Grout <br /> I I trrigation —.Approx. Oe I EasternSurface Sea Installed by <br /> Repair Work Done U Type of Pump M.P. <br /> 3 State Work <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAiR/ADDITION I 1 DESTRUCTION I i INo septic system permitted if public sewer 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 a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments C\ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest' Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines � � '�- -Total length/size ' <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS Ll 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 qr I'cen 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 i auc ,mariner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the totlowin : "I certify at 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 all i " <br /> The Lica u tail for all red in action . Complete draw ng on re a side. <br /> Si <br /> no Titl - Date: <br /> FOR DFPA NT USE ONLY <br /> Application Accepted by nI.A Ia Date LID_11I.O`1 2 Area Z !� <br /> Pit or Grout inspection by Date Final Inspection by IDate <br /> Additional Comments: 1 <br /> 4 <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 /> + <br /> FEE AMOUNT DUE AMOUNT REMITTED CX <br /> lCAH RECEIVER 9Y DATE PERMI7NO. <br /> EH -24{AEV.iiHSYnCrVV y 20 Z Z 3_!_ <br /> EH 14•Te <br />