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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 <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 Services. �!�► E <br /> �C <br /> ,(� ,R+ hot Size/Acreage <br /> Job Address n— fl 6` �� �" City CO-`� <br /> � rt� 1 ` .fir JQ 7 <br /> Owner's Name -+'+��_— Address Phone <br /> Contfactor -T s Address 1"b h�_ _ License No T Phon <br /> r'= tTYPE OF_WELL/PUMP: J,�NEW WELL WELL REPLACEMENT 1 �DEST,RUCTION ❑ Out of Service Well L-1 <br /> `- PUMP INSTALLATloo,� i SYSTEM REPAIR ❑ OTHER'❑ Monitoring Well ,L� <br /> "OtST4NCE TQ'NEAR ST'SEPTIC`7ANKx _SEWER.LINES DISPOSAL FLD. PROP. LINE' �1M <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ;,a, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation 1L, Dia. of Well Casing; _ <br /> fa'Domestic/Private :&(Gravei Pack p�� Specifications <br /> ❑ Tracy i Type of Casing_ k <br /> Il Public 11 Other 1-1 Delta F Depth of Grout Seal Type of Grout <br />' I' Irrigation 1•'46.Approx. Depth l 1 Eastern { Surface Seal Installed by At r} <br /> r' H.P. f _ State Work Done <br /> Rep-air.Work Done v Type of Pump � - <br /> Well Destructionf ❑ Wetl Diameter Sealing Material & Depth <br /> Depth _- Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I i DESTRUCTION l 1 (No'epfi system permitted if public sewer is ., Y <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> "Number of living units: Number of bedrooms t 1 <br /> Cha ct re 'of soil to a depth of 3 feet: f Water table depth <br />- SEPTIC TANK ` �C3 Type/Mfg f Capacity No. Compartments 'V <br /> PKG,TREATMENT PLT.0 ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of tines �� Total length/size <br /> FILTER BED ❑ Distance to nearest: rWell Foundation Property Line <br /> SEEPAGE PITS 11 Depth 'Size Number <br /> SUMPS LI Distance to nearest:- f'Well Foundation Property Lina <br /> DISPOSAL--PONDS ❑ <br /> I hereby certify that 1 have prepared this application and''that the work will be done in accordance with San Joaquin county ordinances, state larfs,_ar: <br /> 'iules 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 n is issued, I shallo� <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor' rt niub-contracting signature's <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall am to ersons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must ca or require inspections. Complete drawing on reverse side. <br /> Signed X Ism ! Title: 1rJ�.t/ �' Date: 1.0—i —y Z <br /> t FDEPA M NT USE ONLY <br /> Application Accepted by a Date Z Area <br /> Pit o Gr Inspection by ate fes'/ ZFinaI Inspection by at <br /> Additional Comments: r f <br /> - � a <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> r Environmental Health Permit/Services <br /> J[ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOVNT DUE AMOUNT REMITTED CK 8 GASH RECEkVED BY DATE PERMIT'NO. AT <br /> INFO r� <br /> L>1 J�iQ� 13 4.1 �� 2�`I3 la-�`1'z 92^ q <br /> . EH 53.24OIEV.,/MSS <br /> EH t4.2e <br />