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r SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 19HEA��H <br /> P O BOX 2009, STOCKTON, CA 95201ENVIRONMENTAL <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> (Complete .in Triplicate) <br /> A <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in complianee frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Sery ces. <br /> i City Lot Size/Acreage <br /> k Job Address J <br /> ' Address yj� <br /> !YI E— Phone <br /> Owners Name ` <br /> 1 f C <br /> Contractor <br /> Address - License No. 404.0 . Phone <br /> CT <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT n DESTRUCTION Cl Out of Service ell <br /> OTHER C3 Monitoring well L] <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK `�pITSYSUMPS' <br /> FOUNDATION-� ' AGRICULTURE WELL ' OTHER WEL.I�� <br /> + INTENDED USE TYPE OF WELL" PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia of Well Casing <br /> n Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation _ <br /> Type of Casing_ ' Specilications <br /> El mastic/Private ❑ Gravel Pack It ❑ Tracy _�..,.V_ Type of Grout <br /> i Public 1-1 Other j n Deka Depth of Grout Seal <br /> it, <br /> i I Irrigation Approx. Depth, II/I�Eastern // Surface Seal Installed by ' <br /> Repair Work Done L7 Type of Pump �� H.P. --J�� State Workpone <br /> r <br /> Sealing Materiel & Depth <br /> Well Destruction ❑ Well Diameter — <br /> i ;Depth Fiber Material & Depth � <br /> I <br /> r is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITION l I DESTRUCTION I 1 availableiNo lwthin 200 feet3.Ied 'f public sewe <br /> l Installation will serve: 'Residence Commercial_ Other _ <br /> Number of living units:' Number of bedrooms <br /> Character of soil to a depth of 3 fee:i Water table depth <br /> SEPTIC TANK. 0 Type/Mfg -=-- *-- - —Capacity--- _ —No.-Compartments <br /> y Method of Disposal <br /> PKG. TREATMENT PLT. ❑ x ° <br /> Distance to nearest:. Weil. Foundation _ _ Property Line <br /> 1 <br /> F <br /> LEACHING LINE 0 No. & Length of lines <br /> Total lengthlsize <br /> FILTER BED ❑ Diiiance to nearest: Well Foundation _P.roperty_Line <br /> i <br /> '` Number <br /> r <br /> SEEPAGE PITS 11 <br /> Depth Size f l <br /> SUMPS Cl Distance to nearest: Weil '_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,-d(dinances, state laws, and <br /> + rules and regulations of the San Joaquin county r - --- <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, !shall not <br /> employ any parson i such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followi 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 Calif r I <br /> The applies mu all for all requi inspec o s. Complete drawing on qr, ide.Title: Date:Signed 1.R DEPARTSE ONLY <br /> Application Accepted by j Date <br /> Pit or Grout Inspection by. <br /> Date Final Inspection by - Dete Z <br /> I Additional <br /> Applicant - Return all copies to: San Joaquin County'Public Health Sery <br /> Environmental`fiekith Permit/ServiceBI <br /> . 445 N San Joaquin, P O Box 2009', Stkn, CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT NO, <br /> AMOUNT DUE AMOUNT REMITTED CASH- <br /> . EH 13-24 IREV.i i ms) <br /> EH 14.26 <br />