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I SAN UIN COUNTY PUBLIC HEALTHVICES <br /> VIRONMENTAL HEALTH DIVISIO T14 y 10 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EKPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1a 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 /> Job Address��S�-�*i-6j C.t <br /> ,,����//�� Y Lot Size/Acreage <br /> ��q / <br /> Owner's Name �1prU �� Address IS 7, CAqS'3� PhoneGa_( - R' <br /> Contracfo Address/�phone 2 <br /> ice No. O <br /> TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 /> OL Industrial ❑ Open Bottom O Manteca pia. of Well Excavation _ <br /> 1] Domestic/Private XGrsvet Pack Cl Tracy Type of Casing_ `'f <br /> Dia. of Well Casin <br /> I'1 Publics Specifications <br /> I.1 O)her n Delta Depth of Grout Seal A- �[j�— Type of Grout <br /> 1 I Irrigation 't'Z.W A <br /> pprox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump <br /> H.P. State Work Done _ <br /> Well Destruction ❑ Well DiAM#t6f Stealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1-1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence` Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of toll to a depth of J feet: - Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT OLT.0 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Lin T <br /> F_ <br /> LEACHING LINE C1 No. 6 Length of lines Total length/size i7� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Limn' <br /> SEEPAGE PITS 11 Depth Size Number Rylas <br /> SUMPS U Distance to nearest: Well Foundation Pro� Tp1 HEALI H DIVISIO"'I <br /> DISPOSAL PONDS O <br /> I hereby certify that 1 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 /> 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 California." <br /> The applicant <br /> must call for all required In pections. Complats drawing on reverse side. <br /> Signed X Title: s <br /> Date: <br /> OR DEPARTMENT USE ONLY (� <br /> Application Accepted by Date Ze2 <br /> Additional Comments: <br /> Area <br /> Pit or Gout inspection by bate Final Inspection by <br /> Date <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 AMOUNT REMITTED K <br /> INFO RECEIVED BY DATE PERMIT'NO. <br />• EN U 24(AEV. (YV I <br /> EH 14.20ym . <br /> F <br /> ggI <br /> _ A <br />