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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .; , ', <br /> ENVIRONMENTAL HEALTH DIVISION <br /> r"I <br /> ; 5 ` <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> "" E <br /> P O BOX 2009, STOCKTON, CA 95201 1 U L U 9 1082 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID ,NVIRON MENTAL HEALTH <br /> (Complete in Triplicate) PERM IT/SERVICES <br /> Application is hereby made•to Sam Joaquin County for a permit to construct andinstall 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 i <br /> Joaquin County Public Health Services. <br /> Job Address P 593 44nEA } - City Lot Size/Acreage <br /> Owner's Name S Address ,15V/a Phone s <br /> rr i <br /> Contractor V Address License No. O1�l---Phone i <br /> TYPE OF WELL/PUMP--, NEW WELL LJ WELL REPLACEMENT V DESTRUCTION Ti Out,of Service Well ❑ <br /> } PUMP INSTALEATION 17 SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO-NEAREST: SEPTIC TANK k SEWER LINES p1SPOSAL FLD. PROP. LINE <br /> x I FOUNDATION + AGRICULTURE WEyLL OTHER WELL PITS/SUMPS <br /> INTENDED USE _-TYPE OE WEI;L„PROBLEM AREA_"CONSTApU TION SPECIFICATIONS d,; = .r;;� <br /> 173 Industrial _ D-Open-9onom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/P •vale ❑ Gravel Pack7 ❑ Tracy I Type of Casing— Specifications <br /> I';I Public Cl Other n Delta i Depth of�G ut Seal; Type f Grout <br /> I 1 Irrigation, —Approx. Depth I I Eastern Surf e,Seal Installed by— <br /> Repair <br /> y Repair Work-D ne U Type of Pump S =_H-P: a� . State Work Done <br /> Well Destructia - -- 2----Well-Diametar�l,-1z _ Suing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTI <br /> C WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION l I Mo septic system permitted if public sewer is <br /> { _ available within 200 feet.) <br /> <Inst I non w -serve: Residence_ Commercial_ Other 1 <br /> Numtier of li units: Number of bedrooms;Characterofit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG.,TREATM•NT PLT. 0 Method of Disposal <br /> t R "'-” 'Distance to nearest: Will oundation Property Line <br /> h <br /> LEACHING`LINk ❑ No. & Length of lines Total. length/size <br /> FILTER (1 Distance to nearest. Wall Foundation Property Line <br /> SEEPAGE PITS` 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> _ DISPOSAL PONDS ❑ <br /> I hereby certify'ihat I-have prepared this application and that the work will be done in accordance withSan Joaquin county ordinances, state laws, andli <br /> rules and fegula`tions of the San Joaquin county <br /> Home owner or,licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ,any pars n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> f certifies the foll wing: "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 /> i tion laws ifglnia." <br /> The applic t /st call for all re fired inspa, ns. Complete drawing on revs side. <br /> Signed X I Title: A n^0Date: <br /> - FOR DEPARTMENT USE ONLY <br /> App lication+Accep ed b Date -Cf L Area <br />!. """Pit or Grput Ihsperaron by ata Final inspection by Data <br /> Additional Comments: r <br /> :.6 f ~Helth Servic;1 <br /> Applicant - Ret rn all copies to: San Joaquin County PubTicaes <br /> Environmental-iealth,Permi.t48erv.ices <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE �,* AMOUNT REMITTED CK ECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 'H 13.24(REV.t/A5) <br /> 1 14.20 <br /> J <br />