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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> AVZ <br /> Owner's Name �� �-Address .� i`�'y�' v'""'"- Phone <br /> r14X0 /Alf /� <br /> Contracto ,dress �"�/ License No. `Mae—,2--Phone <br /> TYPE OF WELL/PUMP: NtW WELL ❑ WELL REPLACEMENT DESTRUCTION,4COut of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR'❑ OTHER ❑ Monitoring 11 <br /> P I <br /> DISTANCE TO NEAREST: SEPTIC TANK �. SEWER LINES �P ALE�FL�.� PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ] <br /> C] Industrial ❑ Open Bottom ❑ !Manteca Dia. of Well Excavation __r_ Dia. of Well Casing <br /> Domestic/Private >CGravel Pack ❑ Tracy Type of Casing_ I specifications4=­0-4&0 <br /> FI Public C7 Other / (l Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation 4;?J9 App ro epth I I Eastern Surface Seal Installed by <br /> Repair Work Done LD Type of Pump H.P. 1 State Work Done <br /> Well Destruction ❑ Well Diameter <br /> ISealing Material & Depthr�� <br /> Depth Filler Material 6 Depth 6192��k= ZL"E A6 v S <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i !No septic system permitted it public sewer is <br /> available within 200 feet.! <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments \ <br /> PKG.-TREATMENT PLT. ❑ Method of Disposal \ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well 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 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 /> 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: "1 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 applicalar 11 r ns. Complete drawing on re a side. <br /> )7 <br /> ' Signed X Title: Date: 10 <br /> FOR DEPARTIIAENT USE ONLY <br /> Application Accepted by + Dateb �Z Area <br /> i <br /> " <br /> Pit or EE>spection by t Data 71f-Finel Inspection by Date !�+1 <br /> d <br /> Additional Comments: r l u.'19 Lab - <br /> Applicant - Return all copie to:-.-San Joaquin County Public Health Services (.AAA A16W 4.71td <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED "CKRECEIVED BY /DATE PERM1TN INFZ �JJ <br /> EM B-24MEV."/n Si ly \ <br /> EH 14.2eZy <br /> � y <br /> PIR 9 <br />