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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 1$62 and the Rules and Regulations of San:. <br /> Joaquin County Public Health Services. <br /> Job Address la ;z y° Tc c h«e-K q-7- City L a d/ Lot Size/Acreage <br /> y <br /> Owner's Name v -v Address <br /> Phone Y <br /> I Contractor �`YZ�iOn. �f SD/Y Address dOdx {3Gvts c/�J Ate& License No. 8q� Phone <br /> TYPE OF WELL/PUMP: .-- NEW WELL•❑ • -. w WELL REPLACEMENT Cl -DESTRUCTION 0 Out of Service well <br /> PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER 0 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FOLD.— PROP. LINE - <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL: PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl lnelusirial 0 Open Bottom 0 Manteca Dia. of Well Excavation_ Dia. o}Well Casing <br /> ' C.l Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> -;— <br /> V1 <br /> Type of Grout <br /> i'1 Public I:1 Other C-1 Delta �- Depthrol Grout Seal ; � YP <br /> I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done, <br /> I Welt Destruction 0 Well Diameter <br /> Sealing Material & Depth l <br /> Depth Filler Material i Depth � w <br /> l TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 11 DESTRUCTION I 1 IN, septic system permitted if public,sawyer is <br /> x available within 200 feet.l <br /> Installation will serve:_ Residence I Commercial_ Other <br /> Number of living units: . _ Number of bedrooms r 5 � <br /> owl' <br /> Character of loll to a depth of 3 feet: ���� Water[able depth � <br /> SEPTIC TANK ,. ❑ T /Mfg l��'� CC's7' -- Capacity Z xog No. Compartments R 4 <br /> Type/Mfg i ,. <br /> PKG. TREATMENT PLT. ❑ Method ot�Disposal `'st <br /> Distance to nearest: Well Foundation j s Property Line e. <br /> ``! tlength/size• <br /> LEACHING LINE C1 No, & Length of lines 7, �' Total <br /> FILTER BED 0 Distance to nearest:' Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size—� �� r Number' <br /> t <br /> SUMPS ktl• Distance to nearest: Well 3�'0� Foundation -, Property Lina <br /> DISPOSAL PONDS Cl I <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, anc <br /> rules and'regulations of the San Joaquin County i <br /> Home owner or licensed agent's signature cenifies the following:-1 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 subcontracting 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 /> r <br /> The applicant must call for all required inspections. Complete drawing on reverse side. { <br /> Signed X Title: 11 Date: Y <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 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 x <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> F • <br /> . EH13-24 WEV.1'.51 <br /> fH 1426 <br />