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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 Sam 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 i <br /> Joaquin County Public Health Services. <br /> Job Address I F s /9 <br /> CCit Lot Size/Acreage <br /> Owner's Nam Address '� Phoria 1 <br /> Contract , , Address (P ! a6ro, License No. �z� Phone r -51®� <br /> TYPE Of WELL/PUMP. NEW WELL 0 WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Weil ❑ <br /> ;PUMP INS TALLATION-❑- A,r. SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> D_ISTANCE,T. NE EST_:,SEP•TIC,TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />"%'— `INTENDED-USE�'Z"""TYPE OF WELL: -PROBLEM AREA`�CONSTRUCTION SPECIFICATIONS; _ <br /> n Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia..of Well Casing;. <br /> ® Domestic/ ""te ❑ Grave! Pack El Tracy Type of Casing_ Specifications Y T <br /> I'I Public 1-1 Other n Delia Depth of Grout Seal Type of Grout <br /> — <br /> I i Irrigation" _Approx. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump ' H.P. State Work gone <br /> Well Destruction ❑ Well Diameter ` Sealing Material A Depth <br /> .(� <br /> - Depth Filler oriel 6 Depth 1� <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION I I REPAIR! ODITION . DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence Commercial Other_ c�� <br /> Number of living'units: Number o droorns at17K <br /> Character of soil to a depth of 3 feet: Water table depth d <br /> SEPTIC TANK ❑ Type/Mfg , Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:. Well Foundation Property Line <br /> LiACHING LINE No. 6 Length of-trines _- _ _- Total length/size <br /> t r � <br /> FILTER BED 0 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-herebycertify that-l-h�Ve piepareditiis'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." <br /> The applicant t call for uir inspectionsZCo ate drawing on reverse side <br /> l <br /> Signed X Title: V �. Date: <br /> FOR DEPARTMENT USE ONLY f �f <br /> Application Accepted by - - _ - ----- Date [1--2 A _ Area <br /> P�or Grout inspection by Date 'fid 'L Final Inspection by <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 /> N <br /> UNT DUE AMOUNT REMITTED RECEIVED BY OAT PERMIT'N0. <br /> (/��E /J �1, <br /> H 13.24(REV,1 5) / {/� �{ r 7 <br /> EH 14.26 f O ✓' <br />