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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 /> 06 L <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 City < Lot Size/Acreage i <br /> Owner's Name T rc. ., k 1�� Address �� r Phone `__'�. 1 / <br /> Contractor s Cr c j� Addressr, ! L cense No. �S 7� S� Phone �r ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I 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 /> l7 Industrial ❑ open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f I Domestic/Private Ll Gravel Pack LI Tracy Type of Casing . Specifications <br /> I'll Pubic (-1 Other 1­1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __ Approx. Depth I I Eastern Surface Saul Installed by <br /> Repair Work Done LJ Type of Pump _ H.P. State Work Done _ \ <br /> Well Destruction ❑ Well Diameter_ Sealing Material & Depth A +_ <br /> Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted it public sewer is <br /> �� available within 200 feet.) <br /> Installation will serve: Pesidence — Cemme,,/rrcral✓ Other s r .A'L_�_' <br /> Number of living units: Number of bed locros <br /> Character of coil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X) Type/Mfg Capacity-/ki,Da No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal a <br /> Distance to nearest: Well _�_ Foundation L_ Property Line 76 <br /> LEACHING LINE V1 No. & Length of lines =_s Total length/size 70 <br /> FILTER BED CI Distance to nearest: Well D Foundation Property Line „3 <br /> SEEPAGE PITS )(I Depth .2 S_ Sire Number <br /> SUMPS LI Distance to nearest: Well f 0 Foundation /0 Property Line nQ C) t <br /> DISPOSAL PONDS ❑ 1��,' <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 subcontracting 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 n3just call fora regyired ins0ectioris. Complete drawing on reverse side. <br /> Signed X , Title: Date: –J <br /> r <br /> 0_ DEPARTh1ENT USE ONLY <br /> Application Accepted by �UJ� ry Date r` Area 1 <br /> Pit or Grout Inspection by Date _ Final Inspection by�t CY+. (��L,- Date <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 <br /> INFO CASH RECEIVED BY DATE PERMIT N0. <br /> EH U-2/(REV I/n s) J'�e ' .(� ✓ •C� '[/t I �� r •Ll t�./�✓ <br /> EN 11.26 �_• �__ <br />