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PERMIT <br /> y SAN 30AQT3IN COUNTY PUBLIC HEALTH SERVICES r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , ATONE CA 952013420 <br /> f P 0 BOX 2009, STOCg , ,L• <br /> FROM DATE ED <br /> DFRIYT'l' H-jLYIRES 1 YEAR <br /> f (Complete in Triplicate) <br /> Application is hereby <br /> made to San"Joaquin County for a permconstruct and/or install the work herein described. This <br /> it to <br /> application is made in compliance with San Joaquin County or <br /> No. 549 and 1862 and the Rules and Regul"a"tions of an r <br /> Joaquin County Public Health services. �� �� Lot Size/Acreage <br /> City �o <br /> Job Address J G ! �ariC.is►P <br /> Jr _ Address <br /> � L Phone <br /> Owner's Name / Rq f ' <br /> Address " , �'_0 License No —phone <br /> Contractor DESTRUCTION ❑ Out of Service Well ❑ !y <br /> NEW WELL ❑ WELL REPLACEMENT ❑ OTHER p Monitoring Well ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ l <br /> PUMP INSTALLATION ❑ DISP SAL FLD. PROP. LINE <br /> SEWER LINES ---- pITSISUMPS <br /> Ir DISTANCE TO NEAREST: SEPTIC TANK �---- AGRICULTURE WELL HER WELL�� <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO d UCTION SPECIFICATIONS Dia of Well "Casing <br /> y is, of.Well.Excavation_ <br /> Cl industrial ❑ Open Bottom ., C] Manteca— -" Specifications <br /> L� Tracy Type of Casing 1 Type of Grout <br /> C) Domestic/Private ❑ Gravel Pa rk n to Depth of Grout Seal <br /> CI Public I"1 Other ` <br /> Saw installed by <br /> 11 Irrigation —.Approx. <br /> Depth I Eastern Surface SeH.P.of Pump State Work Done <br /> --- (1 <br /> Repair Work Done O Type Sealing Material fr Depth �J 1 <br /> Well Destruction ❑ Well Diameter <br /> Depth t � Filler Material & Depth <br /> available within 200 feet.) <br /> TYPE OF;SEPTIC WORK: NEW INSTALLATION I"kr PAIRIADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> a <br /> installation"will serve; Residence <br /> Commercial other <br /> Other <br /> I! / <br /> \ F. <br /> Number of living units: Number of bedrooms — Water table depth <br /> 4 } <br /> Character of soil to a depth of 3 feet: mx Capacity No. Compartments <br /> " SEPTIC TANK ❑ . TYPOMfg ' _� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> ' Foundation Property Line ------ <br /> ;4d01stance to nearest: Well <br /> a .,f, Total lengthlsize <br /> 0 No. & Length of lines <br /> LEACHING LINE f <br /> i F,ound'ation -� �--- Property Line�-- <br /> 4• FILTER BED ❑ Distance to nearest: Well : <br /> : -- __�---------�Number � <br /> l l I Depth Size <br /> SEEPAGE PITS Foundation— property Line -- <br /> ` SUMPS hl Distance to nearest: Well <br /> r <br /> state laws, an <br /> DISPOSAL PONDS ❑ <br /> I have prepared this application and.that the work will be done in accordance with San county ordinances, <br /> I hereby certify that this permit is <br /> rules and reguiations of the San Joaquin I County ollowing: work for <br /> Home owner or licensed ma nesignature certifies the fr as to become subjects to workman's rtcompensation lawsoof California.@ Contractor sFhiring OF sub-cont act ng signatuQe <br /> employ any person in such <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall - <br /> �employ persons subject to workman's compans <br /> ' tion laws of Calilornia." _ _­ . ---.�.-w.�---^F�-�"" � ' <br /> The applicant must call for all required ' specti ns. Complete drawing on reverse si e• —27 <br /> f Date: {/ <br /> Title: <br /> Signed X <br /> Tr4 p " ENT USE ONLY / <br /> ! Date Area <br /> Application Accepted by Date 1� c <br /> Date Final Inspection by <br /> Pit of Grout Inspection by <br /> — <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Perm, Stockton. <br /> f 1(01 E, Hazelton Ave_ P 0 Box 2OD9, 3tockton, .GA 95201 <br /> k CK RECEIVED BY DATE PERMIT"NO. <br /> FEE MOUNT DUE AMOUNT REMITTED CA H <br /> ' INFO <br /> 10 1�_ <br /> Y ' Eli 13-24(REV.$/H5) i <br /> EH 14-26 <br />