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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ' <br /> 445 N SAN JOAQUIN, PHONE (209)46$--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRES 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 c r� <br /> PP compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of Sar1� <br /> Joaquin County Public Health Services. <br /> Job Address 'v� <br /> rr� City �"'�� hat Size/Acreage <br /> Owner's Name �L Address Phone <br /> Cantrac r , Address -Q 0. r70VZZZrLicense Na. Z.� Phone lar <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well G7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ! DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL -OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications ` <br /> 1'1 Public 1-3 Other ❑ Delta Depth of Grout Seal Type of Grout $ <br /> I I irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work hone ,• �"" w ` <br /> Well Destruction .:-- ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth �� V <br /> TYPE OF SEPTIC WORK: NEW INSTAL TIO I 1 REPAIR/ DOITIp DESTRUCTION I I INo septic system permitted it public sewer is <br /> available i within 2001eet1 <br /> Installation will serve: Residence Commercial Other <br /> ti Number of living units: Number of beq( ms <br /> Character of soil to a depph of 3 feet: Water table depth 71 <br /> SEPTIC TANKType/Mf . Capacity.��Q No. Compartments.V ' <br /> PKG. TREATMENT PL , ❑ r —Method of Disjoosal_ <br /> ;Distance to nearest: Well 50 Foundation Property-Line ` ' <br /> LEACHING LINE ❑ No. & Length of lines -7A6;6 Total length/size rI'" <br /> FILTER BED C-1 Distance to nearest: Well Foundation jQ r Property Line <br /> Zl J 't <br /> SEEPAGE PITS 11 Depth Size Number ,r .y <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> �., <br /> I hereby certify that f have prepared-this application and that the work will be done in accordance with San Joaquin county nFdinarices,slat`s laws, an �- <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 shalt not ,E <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-Antracting 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 rti <br /> tion laws of California." � <br /> The applicant st call fo re fired inspections. Complete drawing on reverse i e. <br /> Signed X Title: f ,g (� 7 <br /> Date: �-1" L"�"'.7 J . <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byqiplDate —� Area L , <br /> Pit or Grout Inspection by Date 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 85201 <br /> FEE <br /> INFO /AMOUNTTDUE AMOUNT REMITTED CASH RECEIVED BYD(A'TEE PEERMIT'NOO. <br /> . EK1324SREV.tin51 0 -.!, fJ'1� '+�' e�- 7"7"✓ J"��e7 <br /> EM t�•2e <br /> i - <br />