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I <br /> 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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ! 1. <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. 54,9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> Job Address / ,� t�-� �A6 Z�Z A _6_— City / Lot Size/Acreage <br /> t <br /> Owner's Name Address Phone <br /> F <br /> Contractor z <br /> ` dress b OP License Noi;;� . s�S Phone f <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT F1DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ e OTHER ❑ Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ( SEWER LINES ' } DISPOSAL FLD,. PROP. LINE <br /> FOUNDATION r AGRICULTURE WELL OTHER-WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1.1 Domestic/Private Cl Gravel Pack ❑ Tracy_ Type of Casing_ Specifications <br /> I'I Public 1-1 Other f Cl Delta`. Depth of Grout Seal Type of Grout ^l <br /> I I Irrigation —Approx. Depth I I Easte',rn Surface Sedl Installed by V I <br /> Repair Work Done L] Type of Pump s'.H.P. State Work Done_ <br /> Weil Destruction ❑ Well Diameter Sealing Material & IIepth <br /> Depth ' Filler Nateritil & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION P>< REPAIR/ADDITION I'I, DESTRUCTION I I lNo septic system permitted if public sewer is t <br /> available within 206 feet.) .� <br /> Installation will serve: Residence v Commercial �3 Ot_her <br /> Number of living units: _ir Number of bedrooms c' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg t - `+ " ___ Capacity No. Compartrnents <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �} <br /> Distance to nearest: Well6_ j oundation � � / .Property Line lOD �r <br /> LEACHING LINE ❑ No. & Length of lines 4 Total length/size <br /> FILTER BED <I�Distance_lo_riearest:- Well"''/4''11 oundation Property Line' <br /> i <br /> SEEPAGE PITS I I Depth ,Fr Si 1 — to Number <br /> F SUMPS � Distance to nearest: Well &. Foundation . Propery Line <br /> DISPOSAL PONDS ❑ r C04r( ccw` <br /> I hereby certify that I have prepared this applitetionand thaf 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 subcontracting 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 must call ZforrFeqired inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by w Date 1 Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: K11. \ <br /> Applicant - Return all copies to: San Joaquin County Public Health­S rvices <br /> Environmental Health Permit/Services. , <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA'95201 <br /> ~� •�. --FEE--AMOUMT`f)UE r -"AMOUNT-REMITTED -'CK �"'RECEIVEDBY' -`'—OATE""""'""' "'-PERMI_f'NO'-- " <br /> INFO <br /> . EH 13-24(REV. w 51 <br /> EH 14.26 <br />