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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 /> f (Complete in Triplicate) <br /> Application is hereby rade 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 Coun^ty fPublic Health Services. h <br /> j Job Address ��5 3 1,g e-k 1—C1 City > Lot Size/Acreage G� <br /> f <br /> Owner's Name Ce" Address OL �l� Phone <br /> Contractor $] Address License NoOTV-38Phone -� 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONX0ut of Service Well 0 <br /> PUMP INSTALLATION ❑ / SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> '+ �T$ N E TO N [C-TANK SEWER'LINES"�z"- - DISPOSAL--FLf} —PROP--t:INE --� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AflEA CONSTRUCTION-SPECIFICATIONS " <br /> ' n Industrial ❑ Open Bottom ❑ Manteca' Dia. of Well Excavation Dia. of Well Casing <br /> f t Domestic/Private ❑ Gravel Pack ❑ Tracy, Type of Casing_- Specifications <br /> Il Public 1-7 Other I'"1 Delta Depth of Grours alp Type of Grout <br /> I I Irrigation _Approx. Depth 14 Eastern f Surface Seal Installed by <br /> Repair Work pone U Type of Pump H.P. tate WofIL Dan _ <br /> Well Destruction Well Diameter Sealing Material & Depth " e K <br /> Filler Material le Depth j <br /> Depth h / P ,. rn,,.-TYPE OF OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> h. available within 200 feet.) <br /> Installation will.serve: Residence Commercial_ Other - <br /> Number of living units: Number of bedrooms ` ) <br /> Character of'soil to a depth of 3 feat: Water table depth Y_ <br />►�►� SEPTIC-TANK. ❑ Type/Mfg Capacity No. Compartments f' <br /> P_KG.yTREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Pioperty Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 j <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 i' --_ f <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 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 f <br /> certifies the following: "I certify that3in the performance of the work for which thisermit is issued, I shall employ <br /> ;F <br /> tion laws of California.." i t ! <br /> q p y persons subject to workman's compensa p <br /> The applicant must call for all required inspections. Complete drawing on 'reverse side. l <br /> ' t <br /> Signe Title: 'See_- 6 E fir_ :ZZI 41lqQ <br /> Date: <br /> 'gLafZARTMENT USE ONLY I i <br /> ll 6 <br /> Application Accepted by <br /> Pit or Grout Inspection by � Date _ _ Final inspection by at,, --' <br /> 2 <br /> Additional Comments: <br /> Applicant - Return all copies 'ito: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009; Stkn, CA 95201. <br /> CK <br /> pp130 ?pAMOUNT DUE AMOUNT <br /> REMITTED ASHf'1 RECEIVED 9Y rf�DATE Z_ PERMIT'N0. <br /> EH 14-26 EH IRE1l.i/"$1 W L IAV e S 17 lr ,3B / ) •_qY �� <br /> a z� <br /> o.vo 9 <br />