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` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 i <br /> IP 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 (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 2862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.� <br /> I `�D , X � , <br /> Job Address City Lot Size/Acreage t- �'�_ <br /> a�� k . <br /> Owner's Name Address `�f , Phone <br /> Contract ,� r Address- yJ[ �f�/ / (,1G .._License No. 1z� Phone <br /> TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT lel DESTRUCTION ❑ Out of ServicesWell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I'I Public CI Other Cl Delta Depth of Grout Seal Type of.Grout <br /> I I Irr.i{fation —.Approx. Depth l I Eastern Surface Sedl Installed by <br /> Repair Work Done L7 Type of Pump< H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> i Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I flEPAIR! DDITION DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence Commercial Other ` <br /> Number of living units: _E�_ Number of ms <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. D Method of Disposal <br /> 4_i <br /> Distance to nearest: Well -Foundation Property Line <br /> LEACHING LINE ❑ No. 8 leng,`th of lines E - T,otal length/size 42 117z� <br /> 411-TER BED Distance to�nsarest: Wall Foundation Property Line S <br /> ^'SEEPAGE PITS 11 Depth. Number <br /> SUMPS Ll Distance to nearest: Well f Foundation Property Line <br /> "DISPOSAL-PONOS- 0�--� <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, , <br /> Home owner dr licensed agent's signature-certifies the following: "I certify,thai in the part6jrmance 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 eertify that in the performance of the work for which this-permit is issued, f shall employ persons subject to workman's compensa- <br /> tion laws of California." , <br /> The applic ust callr I r wired inspections. Complete drawing on reverse side: <br /> Signed X 1 Title' '� ��• " ' Date: <br /> FOR DEPARTMENT USE ONLYI #r, <br /> Application Accepted by Date 2 `l, Area <br /> Pit or Grout Inspection by Date Finalinspection 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 2006', gtkn,'d, '95201 <br /> FEEf AMOUNT DUE AMOUNTIREMITiED CK RECEIVED BY DATE P RMIT'N <br /> 0 <br /> INFO CASH <br /> + EH 13-21(REV.tiKSl ! 1 rO0 <br />