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SAN%,JOAQUIN COUNTY PUBLIC RESALTH SERVICES <br /> -L- ENV I RONMENTAL-HEALTH DIVISION-- .�---'— <br /> P r 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Service <br /> Job Address l- (' /' ����o � C1TY Lot Size/Acreage _ <br /> Owner's Name Address Phone <br /> Contractor �� Address nse No, Phone <br /> TYPE OF WELL/PUMP: i NEW WELL WELL REPLACEMENT DESTRUCTION l : Out of Service Nell C) <br /> PUMP INSTALLATIfN V SYST A REPAIR OTHER L - -Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _i���'_`-�/_gg EWER LINES POSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> � .. INTENDED USE_ .TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC 4�4S y <br /> Li 4n trial pen Bottom ❑ Manteca 1[iw of Weil Exc_evahon O,a:of Well C�SirTg ' <br /> Domestic/Private C Gravel Pack ❑ Tracy Type'Iof Casih¢_ Specilications'f -. <br /> ['I Pu�bl'c 1•1 Other C1 Delta `Depth of G out Seal Ty of Grout <br /> 16.ifrigation=- t Approx, Oe I I Eastern `Slirfac`e Sedl Installed by f ti <br /> r z <br /> Rep.air Work Dane U Type of Pump 114.1, N.P. State Work Done ` <br /> We14 Destruction ❑ Well diameter Sealing_ rial 6 Depth <br /> y , — -- <br /> Depth Filler bWterlal 6 Depth <br /> TYPE OF SEPTIC WORK: NEWJNSTALLATiON,1 I i REPAIR%-ADDITION I-I DESTRUCTION I 1 fNo septic system permitted if public se er is <br /> av_ailabfa within 200 Leet1 <br /> f Installitt se+se: Residence <br /> � _ Commercial -Other <br /> Number of living units: ''�Number_of bedrooms <br /> Character of soil to a depth•of'3 feet: _-�I Water table depth :v.. <br /> SEPTIC TANK Cl `-Type/Mfg �- Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal # <br /> I }DIMance to nearest: Well Foundation -Property Line j <br /> , v <br /> / f <br /> LEACHING LINE 0 1,�,Ni . & tength.of lines_ I Total length/size ` t <br /> FILTER BED ID ; Distance to nearest: Well Foundation Property Line <br /> L <br /> I SEEPAGE PITS I•I_Depth _ Size Number <br /> SUMPS L; , Distance to nearest: Well Foundation_ Property Line <br /> DISPOSAL PONDS ❑ <br /> ' 1 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 /> e rules and regulations of the Sari,Joaquin County <br /> Homs 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 be Is subject to workman's compensation laws of California.:LrContractor's_hiring or_sub-contracting signature,. <br /> 4 certifies the following: "I certify that i the pertormsnct`of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> 4 tion laws of California-" _ 0 <br /> The appGca t t all for all to ed in coons. Complete drawing on re <br /> F <br /> Signed Title: Date: <br /> t <br /> j F R DEPARTMENT USE ONLY <br /> Application Accepted by E Date , 1Z-� Area <br /> Pit or Gut Inspection by Date Final Inspection by Date <br /> Irv,Additional Comments: <br /> 4 � p <br /> Applicant - Return all copies to: San Joaquin County Public ealth Services <br /> r Environmental Health Perm t/Services <br /> 445 N San Joaquin O B x 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOU T REM TIED 6 C k H RECEIVED BY A7 P RMIT NO. <br /> INFO <br /> EH 114 <br /> J <br /> . EH t744 1lIfV.liner g4 <br /> r <br /> s� i <br />