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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 O <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I/PERMIT E%PIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> Al-plication 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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Ser, <br /> 3 <br /> Joh Address� ` V c ttCk-7 ��-'C•' Cite Lot Size/Acreage --- <br /> Phone <br /> Owner's Name Address <br /> Cont act6t . �u� Address License No D Phone _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION Ll Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR Ll OTHER ❑ 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 /> 1 ! Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f 1 Domestic/Private ❑ Gravel Pack (A Tracy Type of Casing.-._ Specifications <br /> I'1 P+ihlic 11 Other f-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by <br /> Ranair Work Done Ll Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth filler Material i Depth <br /> I vF'E OF SEPTIC WORK: NEW INSTALLATION REPAIR ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other . r j <br /> Number of living units: Number b rooms +� <br /> Character of soil to a depth of 3 feet: �A!, 1. Water table depth Q <br /> SEPTIC TANK Typs/Mfg dlt�L Citiaciti�=rt—., No. Compartments <br /> PKG TREATMENT Off Cl I � � � Method of Disposal <br /> Distance to nearest: Well 5a Foundation S Property Line _s�2 <br /> A Ilk <br /> I F.ACHING LINE No. 8 length of lines d 40 f' lal length/size yV x-z D6 X-Z <br /> Fit TER BED C] Distance to nearest: Well / Properly Foundation � Pro art line S <br /> SEEPAGE PITS Depth S' Size JTr _ Number o[ <br /> SUMPS LI Distance to neatest: WAII �— Foundation __�O � Property Line <br /> D!SPOSAL PONDS ❑ <br /> 1 hershy 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 /> rnAes and regulations of the San Joaquin County <br /> dome 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 /> amnloy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> r wr-fias the following: "I certify that irl the performance of the work for which this permit is issued, I shell employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicantall for all Iffed inspections. Complete drawing on reverse std <br /> Sipned K \ Z <br /> Title: t Date: J ___ <br /> FOR DEPARTMENT USE ONLY <br /> Arq,liceuon Accepted by !-�� L�LL r! Date -Q Z Area lie <br /> Pio or Grout Inspectionby� Date ZO- T-92'Final Inspection by Data ID-12-9 <br /> Additional Comments: �y <br /> iPPliennt - Return all copies to: San Joaquin County Public Health Serices Ti�{-moi C <br /> Environmental Health Permit/Services n <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ( 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO <br /> . EN 1 LIP.EV. vMSi 5 // d <br /> i � <br /> fH11.le Ir <br />