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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 <br /> .�_P[/µ,blit Health Services. 0 <br /> Job Address `-� , 4� i Lot Size/Acreage <br /> I <br /> AV I <br /> Ne e d ess Phone�, 4�dVr • n Vo, honeAers <br /> i or eTYPE OF WELL/PUMP: NEW WELWELL REPLACEMENT--. DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR D OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES`- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL T OTHER Wkl_ PITS/SUMPS <br /> e <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> -b&mestic/Private ❑ Gravel Pack ❑ Tracy i Type of Casing_. <br /> = Specifications <br /> V1 Public I-1 Other n Delta �1 Depth-of.Grout-Seal Type of Grout <br /> # I Irrigation —Approx. Oqpsb I A EasternSurface Soul Installed by { <br /> Repair Work Done 0 Type of Pu H.P. " ~T-State Work Do <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material,.&-Depth, <br /> Depth , . . 'Fillir Material.& depth r t <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 11 REPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted it public sewer is <br /> 'dvail4ble within 200 feet.1 <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 y� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Propeny Line t <br /> SEEPAGE PITS 11 Depth Sire 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, an <br /> rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies the following: "t 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 applic sl call or uired inspections. Complete drawing on re e sid <br /> gig 6" Title: Date:` r <br /> �Z - <br /> R DEPARTMENT USE ONLY(f7 <br /> Application Accepted ¢y Date d� " ' Area <br /> Pit or Grout Inspection by Date Final Inspection by I, 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 O Box 2009, Stkn, CA 95201 w_ <br /> FEE AMOUNT DUE AM UNT REMITTEDCK RECEIVED BY DATE PERMIT'NO. <br /> INFO �9 <br /> . EM 17-24 IREV.Iinsi % r <br /> EH 11.10 <br />