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i <br /> ti <br /> SAN JOAQUIN COUNTY�PUBL t+ HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> r <br /> ( P 0 BOX 2009, STOCKTON, CA 95201 <br /> `a 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> . C <br /> Job Address _ � �• ` City "^� G Lot Size/Acreage <br /> c <br /> Owner's Name, /LLSLCjtiQ Address Y Phone <br /> Contractor Address97 / & TJ_ e License No Phone��� <br /> TYPE OF WELL/PUMP. NEW WELL 17) =WELL REPLACEMENT i1 DESTRUCTION 0 out of Service Well ❑ <br /> PUMP INSTALLATION 15�<- SYSTEM REPAIR C1 OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Woomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications lk <br /> i'l Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth 1 Eastern Surf s4 Seal Installed by <br /> Repair Work Done Type of Pump H.P. f � State Work Done <br /> Well Destruction\ ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material 3 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDiTION I I DESTRUCTION I I INo septic syslem permitted if public sewer is <br /> available within 200 feet.) (\ <br /> Installation will serve: Residence_ Commercial_ Other 1 <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 <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation _Properfy'Line <br /> LEACHING LINE C1 No. & Lengsh of tines Total length/size �} <br /> FILTER BED 0 Distance toinearest. Well Foundation Property Line l <br /> SEEPAGE PITS 11 Depth I 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 Couaty- <br /> Home owner or licensed agent's signature ceilifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 call far II required inspect) CbmpI drawing on ­se side, j w <br /> Signed X -- Title:- Date:, <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by -Da(Is 4 2_7 L Aree <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 O 130 2009, Stkn, CA 95241 <br /> INFO AMOUNT DUE AMPUNT REMITTED K RE EIV BY DA E PERMIT NO. <br /> s w y <br /> + EM 13.24 IREv.r/K f / <br /> EH 14.28 <br />