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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONICOTAL 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) <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 /> Za1AJZ <br /> le 0 <br /> Job Address Citty/ of Size/Acreage <br /> Owner's Name N Address 77'�I'��� Phone ,2 <br /> ContractgL } K-i14 Address �f: �Z� —License Ivo, Phone bz' <br /> TYPE OF WELLlPUMP: NEW WELL WELL REPLACEMENT C7 DESTAUCTION ❑ Out of Service we11 ❑ <br /> PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHEF; ❑ Monitari//ng l 11 �� <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLO.�PROP. LINE ��fLr � <br /> FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI-O��S-- <br /> Fl.Industrial C��]��Open Bottom MantecaDia. of Well Excavation_fir Dia. of Welt Casing <br /> Vomestic/Private W"GIravel Pack ❑ Tracy Type of Casing jP 1/41C Ar Specifications 40 <br /> 11 Public [I Other n Delta Depth of Grout Seal Ty of Grout <br /> I i Irrigation Approx. Depth *astern Surfa a Seal installed by <br /> Repair Work Done ❑ Type of Pump k H.P. � �� --- State Work Done SAW <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRlADDITiON I I DESTRUCTION I 1 fNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence ommerciel_ Other `' y' <br /> .Number of living units: Number of drooms <br /> Character of soil to a depth of 3 feet: "Water-table depth <br /> SEPTIC TANK O Type/Mfg Capacity_ No. Compartments;, J <br /> PKG. TREATMENT PLT. ❑ �+ Method c.f Disposal„ <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE ❑ No. & Length of linesell <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: undation Property Line <br /> SEEPAGE PITS 11 Depth Size N11 Number A <br /> SUMPS . ,, LI Distance to near .t: Well Foundation Property Line <br /> DISPOSAIPONDS ❑ <br /> I hereby°6ertifyshat'l:have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> roles and regulations of the San Joaquin county <br /> Home owner or licensesignature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ! employ any perso such mann as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> ` <br /> ,• certifies the toll ing: 'I certif t tin thaPerformance of ork for which this permit is issued, 1 shall employ persons subject to workman's com ensa- <br /> tion laws of ifornia." <br /> The applies must II f quired ' s t r ingside. <br /> Signed fa Title: r Date: <br /> on v �f6r <br /> FOR DEPARTMENT USE ONLY <br /> �j <br /> 2­9 <br /> Application�Accepted by Lia Date i" Area <br /> Pit o Grou Inspection by Date Final Inspection by Date <br /> 47 <br /> Additional Comments: 1 P I!R `��y�0 <br /> Applicant •- Return all copies to: San Joaquin County Public Health Services �""""'`�o� j <br /> Environmental Health Permit/ServicesG+W� <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 9520 %T _ <br /> FEE AMOUNT DVE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. J <br /> INFO CASH <br /> �} +� j E� CASH C� <br /> . EH 13-24(REV,I/Ass YVA ��, V V 131/ lig -n-t- 7 -5f� <br /> EN 14.1e <br /> �N LIS, o v 9�� ��,,� <br />