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SAN QUIN COUNTY PUBLIC HEALTH VICES <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 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 Services. <br /> Job Address r City Lot Size/Acreage <br /> Owner's Name Y2p;; 4 45�5 Address !� Phone <br /> Contractor J L Address _ /�-� L20 Z,a77,l- ���License No��Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] <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 /> 0.1ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ _ Specifications �\ <br /> I') Public 1-1 Other P Delta Depth of Grout Seal Type of Grout <br /> I 1.Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by (\ <br /> Repair Work'DOAe 0 Type of Pump H.P. State Work Done <br /> Well Destruction ' ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feetA <br /> Installation will serve: Residence _ Commercial_ Other tK <br /> Number of living units: Number of bedrooms Iff <br /> Character of toil to a depth of 3 feet: hl �/ �-0/+ .a'� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT'PIT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line \` <br /> LEACHING LINE ❑ No. & Length of lines Y� Sy' r-T Total length/siva <br /> FILTER BED Distance to nearest: Well UDF—Foundation =T Property Line <br /> SEEPAGE PITS ( I Depth Size Number _ <br /> SUMPS LI 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 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 /> The applicant must call for al re fired inspections. Complete drawing on�raverse <br /> `side. <br /> Signed X Title: Date: <br /> -21CIDEPA �E-QN1 Y <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection bye '��'" Data <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 AMOUNT REMITTED CK RECEIVED BY ATE PERMIT NO. <br /> INFO <br /> EH 13.24(REV.rix5) <br /> EH 74.26 1, <br />