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SAN JOAOTTIN COUNTY PUBLIC HEALTH SERVTCES <br /> I IRONMENTAL HEALTH DIVISION <br /> 445 N ITAN JOAQUIN, PHONE (209)468-3720 <br /> P 0 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 in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> "Joaquin County Public Health Service <br /> Job Address 20 11 / City Lot Size/Acreage <br /> Owner's Name Zvm- &XZ('A Address -7o- Phone <br /> Contractor l��i4L Address e n s e No. Phone <br /> 'STYPE OF WELL/PUMP: N WELL WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATI N SYSTI OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DJLSPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC IQ�JS y <br /> yC In trial pen Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domek ❑ Tracy Type of Casing_ <br /> stic/Private ❑ Gravel PacSpecifications <br /> F1 Public Cl Other 11 Delta Depth of Grout SealTy e of Grout <br /> ngation — Approx. Dent,, I I Eastern S/trlace Seal Installed by &J,6A . <br /> Repair Work Done U Type of Pump � H.P. f State Work Done _ <br /> 'Well Destruction ❑ Well Diameter _(� z, Sealing Mr.Ceria.1 & Depth <br /> Depth t V Filler Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public seler is (� <br /> available within 200 feet.) <br /> Installation wlhse Residence_ Commercial_ Other <br /> Number of living units: 1. r of bedrooms <br /> Character of soil to a depth-of-3ieet:— — - --Wgte7 fable depth <br /> —SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation PwiQ y Line <br /> LEACHING LINE ❑ 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 LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> .-1 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 /> certifies the following: "I certify tjithe 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 applica t t all for all rens etions. Complete drawing on re r side. <br /> Signed X Title: OF Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by DateArea <br /> L <br /> 'Pit or Gf� Inspection by Date — Final Inspection by � Date <br /> c <br /> Additional Comments: <br /> a Applicant - Return all copies to: San Joaquin County Publ/Bx <br /> alth Services \J�VV�riMA <br /> Environmental Health PeServices <br /> 445 N San Joaquin,�_O 009, Stkn, CA 95201 <br /> _ +IN4,FO AMO�jUN�T{DUE AMOUNT REMITTED CK H III <br /> RECEIVED BY /AT P RMIT N0. <br /> ti t3 211REV.rinsr "' �J y-. V 0 <br />