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- `- SAN ("*)AQUIN CO TTA= PUBIyXC HEALTH RVICES - <br /> 'T — ENVIRONMENTAL HEALTH DIVISI%_e.rr <br /> 445 N SAN JOAQUIN, PHONE (209)458-34208C <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) C 0 <br /> 1 <br /> E Application is hereby made-to San Joaquin County for a permit to construct and/or install the work herein descried. This <br /> application is made 1n compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Seryl <br /> e Job Address Got Size/Acreage <br /> �" )Address <br /> hone�r f3c 40n r' Na <br /> actor ` A d <br /> s <br /> / [1 itense No. ��` Phone ` <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT __ BESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 ustrial ❑ Open Bottom Cl Manteca Pia. of Well Excavation Dia. of Well Casing <br /> vmestic/Private C1 Gravel Pack C} Tracy Type of Casing Specifications <br /> I'l Public is Other fi Delta Depth of Grout Seal Typa of Grout <br /> I I Inigalion T Approx. Dep_0, I I Ea tern1 Surface Seal Installed by - <br /> Repair Work Done 0 Type of Pump H.P. ` State Work <br /> Well Destruction ❑ Nuel! Diamatey « Sealing Material & Depth <br /> Depth !(f Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION t I (No septic system permitted H public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: " �F-` Number of bedrooms <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, Ll <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED L"l Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS 0 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 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 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 Ca' nia." <br /> The epplica m t cal for ired -nspections. Complete drawing on evy9e side. <br /> Sign d Title: Date: � / <br /> RTMENT USE ONLY L7 la— M-12— <br /> Application <br /> a— `g1LApplication Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by �`p� reDate <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 95201 <br /> FEE AMOUNT DUE ANPUNT REMITTED CK H RECEIVER BY D TE PERMIT NO. <br /> INFO <br /> EH13-241REV.iiMaf �f�-� ♦ �/ <br /> EH 14.26 ..r <br />