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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br />€ 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> E P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (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 /> Josquin County Public Health Servi ea. <br /> vwa�� <br /> Job Address Lot Size/Acreage <br /> �y +' <br /> e <br /> Na Addresswe <br /> O War's <br /> ntractor <br /> A d f [s license fVo. Phone�`G` <br /> TYPE OF WELL/PUMP. NEW WELL WELL REPLACEIVIENTr DESTRUCTION Cl Out of service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER C3Monitoring 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 /> n ustrial EI Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casings 4 <br /> ` 4mestic/Private 0 Gravel Pack �L7 Tracy Type of Casing. Specifications <br /> 0 Public 17 Other n Delta Depth of Grout Seal Type of Grout <br /> I Irrigation —Approx. Dep 1 I Ea tern J Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump, H.P. ` State Work _ <br /> Well Destruction " i❑ (Depth <br /> reii Diam a �� Sealing Material & Depth <br /> `� t �i .i '7f Filler Material & Depth <br /> TYPE OF SEPTIC"WOiRK: NEW INSTALLATION ! I REPAIR/ADDITION I I DESTRUCTION I i lNo septic system permitted if pubtic sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: '""'Number of bedrooms ► <br /> Character of soil to a dspthof 3 feet: Water table depth f <br /> SEPTIC TANK. 0 rype/Mfg a/A '- Capacity No. Compartments <br /> iT <br /> PKG. TREATMENT PLT. ❑ e Method of.Disposal `A <br /> ,Distance to nearest: Vi a Foundation` - - --3 Property Line To", <br /> """""'"""'�'_'.'"'"'""".'""""'a Total length/size <br /> LEACHING LINE ❑ Na. $ Length Of lines <br /> FILTER BED ❑ Distance to nearest:' Well Foundation Property Line <br /> f <br /> SEEPAGE PITS___ 4_6epth7' � �SiZe NumberF <br /> SUMPS 0 Distance to nearest: Well Foundation Property tine <br /> DISPOSAL PONDS ❑ ',-)--V VA 4 "�1}�'N '' �_i►�„r r <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws and <br /> rules and regulations of the San Joaquin County I s <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 t <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 Ca' nla." ' <br /> The applica m t cal for fired 'nspections. Complete drawing on rev side.— <br /> .a <br /> k Sign d Title: Date: <br /> M1 RTMENT USE ONLY 9 /Pt- M-12- <br /> Application Accepted by nl - _ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by :`?= 2 Date 2 2r <br /> Additional Comments: f <br /> �n <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 A ybUNT REMITTED CK H RECEIVED BY D TE PEttMIT'NO. <br /> INFO [/ <br /> +�+ EH 13-24(REV.1/x 51 P <br /> L. EH 14.26 f . <br /> i <br />