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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 O BOX 2009, STOCKTON, CA 95201 <br /> 0,0106-2/01— <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rApplication 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 <br /> I Sery `es <br /> , . <br /> ity K_ . Lot Size/Acreage <br /> Jab Address e, `. <br /> Owner's Name C `A-Address - Phone <br /> Contractor Addres� �License f;�Phone — 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L DESTRUCTION 5 out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Wr OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEARES`T; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ` i ''� ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> KDomestic/Private ❑ Gravel Pack "'tb Tracy Type of Casing_ Specifications <br /> I'i Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I <br /> I I Irrigation —.Approx. Dept lel Eastern Surface Seal Installed by <br /> Repair Work Done' Type of Pump � H.P, State Work Dor C <br /> /` Sealing Material & Depth _ <br /> Well Destruction ; © Well Diameter <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 leet.l , <br /> installation will serve: Residence yCommercial Other -' t <br /> Number of living units: Number of bedrooms' <br /> Character of soil to a depth of 3 feet: `` Water table depth <br /> SEPTIC TANK. �,f ❑ Type/Mfg Capacity • • } .No. Compartments <br /> PKG. TREATMENT PLT.❑ f Method of Disposal <br /> { Distance to nearest: Well Foundation Property Line <br /> i` 6_11�; 9 <br /> LEACHING LINE 0 No.`s&'�ength of lines Taal lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation f Property Line <br /> i SEEPAGE PITS 11 Depth Size t't Number <br /> SUMPS CI Distance-to,nearest: "•Property Line <br /> nearest: Well Foundation <br /> DISPOSAL PONDS ❑ i <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 f 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 toworkman's c pensa- <br /> tion laws of Califor ---�- <br /> k Thea must c for all required ins ' ns. plate drawing on r se side. <br /> Signed Title: Date: 9 <br /> ! , FOR DEPARTMENT USE ONLY '} <br /> Application Accepted by _ 11 <br /> 1`� _— Date d LArea Z <br /> Pit or Grout Inspection by Date Final Inspection byAdit4M4 Date 1 %L <br /> t <br /> j Additional Comments: $ <br /> t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 945 H San Joaquin, P ox 2009, Stkn, CA 95201 Al <br /> I FEE AMDUNT DUE AMOUNT REMITTED CK RECEIVED BY DA/E_ PERMIT NO. <br /> INFO10 <br /> . H 53.24{REV.six51 D 1160 <br /> EH 14-261V2 <br />