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SAN JOf, IIN COUNTY PUBLIC HEALTHi Si' CE;< <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (.Complete in Triplicate) i' " <br /> l 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 i862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. z i11 <br /> Job Address 1 -706o ('4A L <br /> city14 <br /> Lot Size/Acreage <br /> gl 599g I a ' <br /> 14� <br /> Owner's Name Address �hona <br /> •0• Q v� a <br /> Frgmmt )10 <br /> Contractors`` 5NS ` V • k le Address L License No. Phone <br /> TYPE OF WELL/PUMP: NW WELL WELL REPLACEMENT F <br /> DESTRUCTION G Ouz of Service Well ❑ <br /> PUMP INSTALLATION ❑ ui SYSTEM REPAIR ❑ .j�! OTHER ❑Monitoring well C3 i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 'r PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEGFIdA IONS' <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio IDia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ f V' L� 'I _ 'ISpecilications <br /> 1'I Public I>4bth r7 Delta Depth of Grout Seal `Type of Grout <br /> I I Irriy r n i ipprox. Depth Il Eastern Surface Seal Installed by It' II <br /> t au ork Oone Type of Pump H.P. Sta4 Work Done <br /> Well Destruction ❑ Weil Diameter "' Sealing Material & Depth .ii <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I ,REPAIRIADOITION ( I DESTRUCTION it INo septic sysibm permitted i{ public sewer is <br /> I available within'200 feet.) <br /> Installation wiil serve: Residence_ Commerciale_ Other �: a ,k <br /> Number of living units: Number of bedrooms , <br /> Character of soil to a depth of 3 feet: ' Water table depth , <br /> r <br /> SEPTIC TANK 0 Type/Mfg _ Capacity ,I No. Compartments <br /> PKG, TREATMENT PLT. ❑ iI Method of Disposal <br /> Distance to nearest: 'Well . 'Foundation I!' Property Line <br /> I <br /> LEACHING LINE ® No. 8 Length of lines Totaldength/size <br /> FILTER BED ❑ Distance to nearest: `Well i Foundation "i' Property Line M!1 <br /> _ a r• � <br /> SEEPAGE PITS 11 Depth Size Number J5 t�t��;t� <br /> -tc�-� � rI�IS,ON <br /> SUMPS LI Distance to nearest: N Well Foundation "' Props t -i Iti L ` <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquiC county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Countyl <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 nott <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following:"I cartify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa <br /> tion laws of California." k <br /> The applicant m all for all req 9 d inspilactions. Complete drawing on revatse side. .I 4 <br /> Signed Title: Date: 417/ 9-2- 5 <br /> i <br /> FOR DE ARTMENT USE ONLY ii i <br /> 5)6­2! <br /> Application Accepted by �~ /y Date M Area ie <br /> Pit or Grout inspection by `+ ate `;�— Final Inspection byf� �k r Date <br /> Additional Comments: <br /> c , .I! <br /> Applicant - Return all copies to: San Joaquin County Public Health Services a ' <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stk'n, CA 95201 Fn r1 J <br /> .c <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH .I <br /> . EM 13-24 Ip£V.It 5) VO <br /> FM 1�.7e .Ij, <br />