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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT SIRES 1 YEAR FROM DATE ISSUED <br /> 1i (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 /> G�tue City Lot Size/Acreage <br /> Job Address .,JIII [/ / <br /> Address Phone <br /> Owner's Name f <br /> Address ����� Yense No. <br /> Phone <br /> TYPE OF WELL/PUMP. NEW WELL 3'� WELL REPLACEMENT ❑, DESTRUCTION ❑ out of service Well L <br /> Monitoring Well <br /> PUMP INSTALLATION SYSTEM REPAIR ! OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK. - EWER LINES �� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> [_l Industrial O Open Bottom El Manteca Dia. of Well Excavation <br /> a <br /> Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Type of Grout <br /> V1 Public (1 Other 1-1 Delia Depth of Grout Seal <br /> 1 I Irrigation !Approx.'De th I I Eastern, Surface Seal Installed by <br /> iRepair Work Done O Type of PumpState p State Work Done <br /> F ,.t Sealing Materiel i Depth A <br /> f Well Destruction O Well Diameser T_ 1 <br /> Depth �O42 Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will serve: Residence—` Commercial— Other— <br /> Number <br /> Number of living units: Number of bedrooms ,,p���! ENT <br /> Character of soil to a depth of 3 feet: W-'a '-Eb E�` <br /> SEPTIC TANK 0 Type/Mfg Capacity No <br /> f McJl1d�o2D9 r <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Propert Li NTY <br /> SN���C-PIR r ES <br /> t + Total le !'pIV1S40 <br /> LEACHING LINE O No. & Lenath of lines <br /> FILTER BED, ❑ Distance to nearest. Well Foundation .o any Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> i 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 /> `t rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I cenify that in the performance of the work for which this permit is issued, I shelf 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 followin : 1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa <br /> tion laws of Calif la. ' IJ <br /> I`t Tho applicant st II for du d ' cti Complete drawing on reverse side. <br /> Signed Title: Date: <br /> SE ONLY r <br /> Application Accepted by <br /> Data t Arse — <br /> 42 <br /> Pit or Grout inspection by <br /> Date Final Inspection by Date Z <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 Box 2009, Stkn, CA 95201 <br /> ` <br /> INFO <br /> FEE AMOUNT DUE; AMOUNT REMITTED ASH R CEIVED BY GATE PERMIT'N0. <br /> I <br /> .4- <br /> EH 13-24IRF/.Iins1115(�� .. <br /> EH t.ae f <br />