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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to SamlioaquinCounty for a permit to construct and/or install the Work herein described. This <br /> I application is made in compliance.vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joiiquin County Public Health Services. e� <br /> City 40� ' Lot Size/ re _ i <br /> Job Address L� <br /> Address if g -! A 106&CE&e I - Phone <br /> Owner's Name <br /> ` ,�}AA <br /> Contractor �� S Address 977 S'c.[rt C e[/'l ._License No, VnqX Phone 4 <br /> TYPE Of WELL/PUMP: NEW WELL © WELL REPLACEMENT .. DESTRUCTION [�.adti of service well 0 <br /> Monitoring Well <br /> } PUMP.INSTALLATION P000 SYSTEM <br /> /REPAIR ❑ OTHER G o <br /> DISTANCE TO NEAREST: SEPTIC.TANK - SEWER LINES DISPOSAL FLO. !!J!C" PROP. LINE' <br /> FOUNDATION - AGRICULTURE WELL �` OTHER WELL [O PITS/SUMPS' <br /> INTENDED USE TY E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 9 <br /> n (Industria! pen Bottom 0 Manteca Dia. of Well Excavatiio�n^ Dia. of Well Casing \ <br /> *1 DomesticlPrivate Cl Gravel Pack Ll Tracy Type of Casing.-�?J<-' � Specifications d <br /> I'I Public M Other "` 171 Delta Depth of Grout Seal Type of Grout ` <br /> I i Irrigation Approx. Depth 4 I Eastern Surface Seal Installed by, n EM _ �3 <br /> Repair Work Done 0Type`of Pump <br /> H.P. State Work Done.� <br /> Well Destruction © Well Diameter <br /> Sealing Material 8 Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feel-.i "* <br /> Installation will serve: Residence Commercial — Other <br /> ^-^ Number of living units: mber of bedrooms --�--•. <br /> Character of soil to a depth of 3 feet:r Water tabled <br /> SEPTIC TANK ❑ Type/Mfg Capacity . ompartments <br /> PKG. TREATMENT PLT. 0 � ry Method of Disposal <br /> Distance to nearest: Well Fo property tine <br /> LEACHING LINE LI No. & Length of lines Total Is <br /> e <br /> FILTER.BED ❑ Distanceto Well Foundation R- Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS A CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS o € <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 <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 /> r 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: "t 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 must all for al require inspections. Complete drawing on reverse sii�de�,�� <br /> Signed Title: � 4"� Date: <br /> DEPA ENT USE ONLY �] F <br /> Application Accepted by Date <br /> Pit or Gt Inspection by { "-;;ate ?/ Final 1 pection b <br /> [[[[((JJJJJJ �1 <br /> Additional Comments: <br /> r <br /> Applicant - Return all copies to: SaJoaquin County Public Health Services <br /> i Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DVE` AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT'ND.INFO CW <br /> - Q <br /> • EN13.2�IREV.,�X51 PIS •� { i, 1 <br /> EN 14.2E <br />