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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 O BOX 2009; `STOCKTON, CA 95201 <br /> t' <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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Count Public Rea th Service . <br /> Job Address S `t ° , JO -- City G"rw/Lot Size/Acreage <br /> \iT • e I S a is Address Phone ~ <br /> Owner's Name M- V V it ---.— <br /> Contractor ` L44,P#%. i Address Q —7 License No. /6,2373 Phone - Z <br /> -TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well M <br /> PUMP,INSTALLATION 12 ¢SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> _ _ f <br /> DISTANCE TO NE4REST: SEPTIG'TANK'� � SEWER LINES DISPOSAL FLD. PROP. LINE 4 <br /> t. FOUNDATION AGRICULTURE WELL OTHER WELL'' L PITS/SUMPS ` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia_ of Well Excavation Dia. of Well Casing <br /> Domestic I Private C1 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 0 Public 1-1 Other (l Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I t astern SurfpG_�_ Seeel Installed by k <br /> Repair Work Done � Type of Pump i� /H.P. Y__/ State Work Done G G @G C+ 4 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> t <br /> Depth ' �', i _ ,, UFiller Noterial & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewet is <br /> { available within 200 feet.) <br /> E <br /> installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg ! Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal y,y <br /> Distance to nearest: -Well ' Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED C1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth 1 Size Number f <br /> SUMPS LI Distance to nearest: Well Foundation^ Property Line <br /> DISPOSAL PONDS ❑ 1 > <br /> 4 <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 /> rules and regulations of the San Joaquin County <br /> Home owner or fico is 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 per in such man r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f lowing: "1 certify t at in the psormance of a work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion taws o California." "— , <br /> ter.. <br /> The appli nt mu c II requi plete wing o r side. <br /> Signed X d Title: .� Date: <br /> OR DEPARTMENT USE ONLY <br /> .a.•, ' a <br /> Application Accepted by Qi, CJIM r Date Area 0 ckl <br /> Pit or Grout Inspection by Data z -Final Inspection gy c4zite <br /> Additional Comments: ' t' <br /> r � I <br /> Applicant •- Return all copies' to: San Joaquin County PubtJe--Health Services / <br /> Environmental Health Permit/Services <br /> !E 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> — CK IINFO AFEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED By M DATE PER14117'fVO. <br /> EH 13.24IREV.iimW <br /> 1ir11�•2e <br />