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SAN JOAQUIN COUNTY PLTBLIC HEALTH SERVICES <br /> Q <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> �Q,90-- ' <br /> afPERMIT E%PiRES 1YEAR 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 Rule and Regula one 4�San <br /> Joaquin County Public Health Services. oply /©y ,r-0 r <br /> Job Address 32- City a Lot Size/Acreage R0,,4 C- <br /> i Owner's Name r►cl Address, (a-�^�1C.,?,/ 4x Phone <br /> Contract •Lr.C� Address Z License NQ32�Phone s7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE :TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F] Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j <br /> Domestic/Private ❑ Gravel Pack 0,Tracy7: Type of Casing_.` Specifications <br /> 1'! Public El Other n'Delta Depth of Grout Seal I Type of Grout <br /> Irrigation #�Approx. Dep; I Eastern Surface Seal Installed by q�] <br /> Repair Work Done X Type of Pump S11 <br /> H.P. __/: State Work Don r.� E2 v" I <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth <br /> Depth Filler Material & Depth 3 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I k INo septic system permitted it public sewer is 1 <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 ❑ Type/Mfg Capacity No Compartments <br /> PKG. TREATMENT PLT. 0. <br /> Method of Disposal <br /> i Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑' No. & Length of lines ^. <br /> 9 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation! =r �Property-Line M1 <br /> s a <br /> SEEPAGE PITS 11 Depth Sire 'Number <br /> SUMPS L1 Distance to nearest: Well Foundation �° *Property Line <br /> DISPOSAL PONDS ❑. ` ' <br /> k L k t <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 s <br /> Home owner or licensed agent's signature certifies the following: '9 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 compensatiori laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fat - certify that in the performance of the work for which this perritit is issued, I shall employ persons subject to workman's compensa- <br /> tion law Califonnia." <br /> The applicant must II for all requir specti s.-Complete drawing on revs se 'de. c <br /> Signed 74/lbw— <br /> Title: p �7 _L y Date: <br /> or <br /> FOR DEPARTMENT�USE ONLY <br /> ' yf . <br /> Application Accepted by __. s"�p _ �--- ` Data Area <br /> Pit or Grout Inspection by Date Final Inspection by 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 0 Box 2009, Stkn, CA 95202 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATEPERMIT�NO. <br /> + EH 13.241REY.Fins <br /> EH t{26 /� / � <br />