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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,XPHONE (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 /> Job Address a 14 <br /> Ciry_S �of Size/Acreage -- <br /> Owner's Name r Address Phone <br /> ., 0 6- Z <br /> Contractor % LA bVL Address Q O 5C License No. Z Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 ,WELL REP_I,AG-MENT `DESTRUCTION Out of Service Well ❑ <br /> j PUMP INSTALLATION p SYSTEM..��R�EPt`IR ❑ ,�OA�T.,H^�ER f <br /> Monitoring Well C7 <br /> DISTANCE TO f�lEAStEST: SEPTIC TANK rs �'} SEWER LINES DtSrOSAL FLD.I� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL =OTHER WELL" 60/ PITS/SUMPS 00 ,'- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATI NS <br /> C-J_1Industrial OpenBott°m ❑ Manteca I Dia. of Well Excav2-' Dia. of Well Casing <br /> 1/0 <br /> fKPomastic/Private Ptravef Pack ❑ Tracy Type of Casing- •�► . �,Specifications <br /> I'] Public C O er4+� IlDelta Depth of Grout Seal Cga � YP ; Grout ` <br /> l'I Irrigation gAppfox. Depth I+t Eastern Surface Seal Installed by <br /> RepairWork Done Type of hump H.P. State*Work <br /> `x Sealing Material & Depth <br /> Well'Des;ructian' [ / Well p.iartater — <br /> I l Filler Material & Depth <br /> Depth <br /> �XPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> j available within 200 feet.) {� _ <br /> Installation will serve: Residence— Commercial_ Other <br /> �f.Number of living units: Numbs f bedrooms i <br /> /�Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments g <br /> PKG"*AEATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: I Foundation Property Line <br /> LEACHING LINE 11 No. & length of lines Total length/Size- <br /> LW <br /> FILTER BED ❑ Distance to nearest: elf Foundation Property LIr1N _ y <br /> SEEPAGE PITS it Depth Sizs : Number <br /> SUMPS I l ,Distanceto rest: Well ) Foun tion Property Line " <br /> DISPOSAL PONDS ❑ f t # r <br /> I hereby 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 /> rules and regulations of the San Joaquin County r <br /> Home owner or li ant's signature certifies the folib4ving: "t certify that in the performance of the work for which°this permit is issued, I shall not <br /> employ any on in such nner-as to became subject to Workrrian's compensation laws of California." Contractor's hiring or subcontracting signature <br /> cart0ie I t following: "I ce ify that in the performanc f the work for which this permit is issued, I shall employ persons subject to workman's compensa (� <br /> tion law of California." ' `\_ <br /> The sp hcant u f all re r s omple tng on r rs 51 0. (� <br /> Signed Title: /y/jf/ Date: <br /> « m T FOR DEPARTMENT USE ONLY <br /> t F Y i <br /> Application Accepted by Date Area <br /> Pit . Grou Inspection by _ Date Final Inspection by pate IF <br /> Additional Comments: b( <br /> Applicant - Return all copies to: San Joaquin County Public Hbalth Services <br /> Environmental Health Perlh1t/Services <br /> 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCAS RECEIVED BY D E PERMIT'NO. ` <br /> INFO / <br /> r EH 13.24(REV.f/x51 LA' <br /> ' ry <br /> fH Ic2s r <br /> k <br />