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t <br /> r SAN CAQUIN COUNTY PUBLIC HEALTH � PIRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> FP 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 yin compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public--Healt ervices. �p <br /> Joh Address f Cl <br /> �` �' Gt.J-k City }�"�` ' Lot Size/Acreage <br /> iOwner's Na f Address `' Phone <br /> Contra or 'Address �" , _7 (r E_icense No�Z��7� Phone l�r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Cl <br /> FPUMP INSTALLATION ❑ SYSTEM REPAIR n OTHER D 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 /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack C) Tracy Type of Casing_ Specifications <br /> F] Public 1-1 Other it Delta Depth of Grout Seal Type of Grout [ <br /> t ! Irrigation Approx. Depth I I Eastern Surface Seal Installed by (� <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ C <br /> [^ Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth ller Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 - RI <br /> EPAIDDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet) <br /> Installation will serve: Re deuce commercial Other <br /> Number of living units: Number f +?booms <br /> Character.of soil to a depth of 3 feet: ` 1 � Water table depth <br /> SEPTIC TANK 0 Type/Mfg - Capacity No. Compartments <br /> 11 PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ; <br /> ,. Distance to nearest: ' Well Foundation Property tine <br /> i <br /> LEACHING LINE >6 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well ` is Foundation f C Property Line _;C _. <br /> SEEPAGE PITS It- Depth Size Number <br /> SUMPS L] Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 11i 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 /> a Home owner or licensed agent's signature certifies the following: "t 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 sub-contracting 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 /> 1 The applicant st I for all r re inspections. Complete drawing on reversie si e �f <br /> Signed /� � Title: L r Date: '` <br /> t <br /> I F1i FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date y Area <br /> II f Pit or Grout inspection by Date Final Inspection by <br /> I <br /> � Additional Comments: a' � <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 2009, Stkn, CA 95201 �{� <br /> + FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17 NO. �V� <br /> INFO / JCASHC <br /> EMU-111t1EV.,tiss; se / [o c7 raO 1 '37 ��S`�� ,3� Q l 611 <br /> CH 11•]a I <br />