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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i <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 /> em�Job Address Y` City 4J�1J/-hrninl Lot Size/Acreage <br /> ]]z,� <br /> Owner's Name �r`'��� � S Address Phone <br /> Contrac --Lift Alter f�:Cr ddsess3Q ltd U ��} License NO.`� Phone <br /> TYPE OF WELL/PUMP: , .NEW WELL'❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION El 'SYSTEM REPAIR C7 OTHER ❑ Monitoring Well ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USt_TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl industrial j ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1") Domestic/Private Cl Gravel Pack �* ❑,Tracy Type of Casing Specifications <br /> I'1 Public <br /> I-1 Others ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __ Approx. Depth i I Easternt Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. i State Work Done <br /> Well Destruction❑Welf Diameter-�.-�,—�"'""�?Sealing.Material 3 Depth <br /> _ Depth Filler Material 8 Depth <br /> �,. TYPI5 OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 111--B'ESTRUCTION I 1 {No septic system permitted if public sewer is r� <br /> ' t ____L 6 K\ ._ X \ 'Y available within 200 feet.) <br /> Installation-will serve:"-ftiidence"�" -Commercial°��her <br /> r Number of living units: Number of bedrooms _ 1 <br /> Charactef of soil to a depth"of 3 feet: "`"`�>A Iy an _ Water table depth <br /> `SEPTIC TANK. ❑ Type/Mfg T Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ r Method of Disposal aj <br /> Distance to nearest: Well Foundation Property line <br /> LEACHING LINE Cl No. $ Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> f "s <br /> SEEPAGE PITS_ tTl Depth Siz'e's !JX,--2-5.KNumber <br /> SUMPS tr'­5istance to nearest: Well WC07 Foundation /0 Property Line_LSA <br /> DISPOSAL PONDS ❑ liv_ - 1 <br /> I hereby cenify 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 /> c ifies 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 of California." <br /> he applica us call f r a re ired ' pec ons Camp rawing reverse si e. <br /> Signe Titin <br /> : Date: 7 - 6:L-47 <br /> / F DEPAR <br /> Application Accepted by Date 6 Area <br /> Pit or Grout Inspection by Date final Inspection b 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 0 Box 2009, Stka, CA 95201 <br /> FEE_. —AMOUNT DUE——AMOUNT-REMITTED-----SK- • . --•RECEIVED"BY' DATE' -—PERMI7." <br /> INFO CASH <br /> . EH1344 tAEV.1/"51 <br /> `/' i� <br /> EH t4.je , • ri 7 <br />