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SANIFUAQUIN COUNTY PUBLIC HEALTH `StRVICES <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 W 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 County Public Health Services. / <br /> y c City rs"�• Lot Size/Acreage %� OxaFEN <br /> Job Address V if <br /> /Owner's Names�o& ­TRo lrjze , Address <br /> `� S <br /> CAICKPhone <br /> P(contraetor ^ U)Ngor Address �- rej�cX '5(�44-"Llcense a <br /> No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL URE WEL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ON RUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Di of Well Excavation Dia. of Well Casing <br /> C'.) Domestic/Private ❑ Gravel Pack ❑ Tracy ype Casing___ Specifications <br /> — <br /> 'I Public 1 7 Other n Delta Depth of out Seal Type of Grout O <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal tall ed by Q <br /> Repair Work Done ❑ Type of Pump P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material a Depth ,^ <br /> Depth Filler Material a Depth V" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will "me: Residence —4 Commercial_ Other <br /> Number of living units: Number of b9drooms <br /> Character of soft to a depth of 3 feet: t D e NJ /�/����� Water table depth 1 <br /> SEPTIC TANK D Type/Mfg Capacity a12Q0 _ No. Compartments <br /> PKG. TREATMENT PLT.❑ Method nof�Disposal <br /> Distance to merest: Well S�d.� Foundation�iLi— Property Line d-'�— <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size 0 <br /> 17 r 350 <br /> FILTER BED ❑ Distance to nearest: well31S , Foundation _,�_ Property Line <br /> SEEPAGE PITS 11 Depth Size Number tA <br /> SUMPS LI Distance to nearest: Well �� Foundation Property Line 1AQ -- <br /> SUMPS <br /> 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 sub-contracting signature <br /> cenifies 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 /> The apylieen1 ust call for all required inspect ons. Complete drawing on reverse side. <br /> Signed X rMai Title: �'l'�1•r\le t�- c Date: t1 —7'� <br /> 1A\�� FOR DEPARTMENT USE ONLY 0111 <br /> Application Accepted by "".Jas=�i `" aclk Data Area <br /> Pit or Grout inspection by Date Final Inspection b_ -'' -� r Oatx <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 gMOUNT DUE AMOUNT REMITTED I CAS,, RECEIVED BY DATE PERMn'NO. <br /> INFO <br /> • EN;::24 IREV.I In 51 1 <br />