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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION w. <br /> Z� ! 445 N SAN JOAQUIN�; PHONE (209)468-3420 1 <br /> P 0 BOX 2009', -STOCSTON, CA 95201 R•'��f�f�' <br /> t c I <br /> } <br /> ,. " 'u3:A PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) <br /> Application is hereby made.to Sam 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 /> k Joaquin County Public Health Services. <br /> L, U� City Size/Acreage <br /> -S I'3 <br /> Job Address— <br /> S� <br /> Owner's Name <br /> Address Phone <br /> �r <br /> .. License No. Z 6 73 Phone b L <br /> Contractor �l ILA Address <br /> TYPE OF WELL/ UMP: NEW WELL ® WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ <br /> ^ / SYSTEM REPAIR ❑ OTHEER ❑ Monitoring Well <br /> I PUMP INSTALLATIOON��1/�, f <br /> DISTANCE TO NEAREST: SEPTIC TANK �l.L� SEWER LINES DISPOSAL FLO.1120 PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �d <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS -� <br /> Dia. of Weil Casing <br /> C1 Ir�ustrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation — <br /> �/ t Type of Casin V' Specifications-- <br /> OomesticlPrivate ravel Pack 0 Tracy 9 r <br /> -' Vww <br /> 4 n Opw (-1 Delta Depth of Grout Seal T pe of Grout <br /> Il Public � � pL <br /> )'Approx..bepth I/Ytastern--,._�_,,,_„Su ace-Seal installed by <br /> Repair Work Done t1Y type at Pump S- H:P.- % State Work Done <br /> . -+" "r ;u. _, —Sealing Materia l & Depth f }7 <br /> Well Destruction � Well D'iameter�-. - V T <br /> Depth °-3^ ( O r ,P �' 4'P':iller Mdteriel'dt Depth n(� <br /> TYPE OF SEPTIC WORK..,NEW INSTALLATION I 1--REPAIR/ADDITION I 1,-,DESTRUCT10N I I (No septic system permitted it public sewer is ._]y <br /> ., e1 r 1 w available within 200 feet.] <br /> { <br /> Installation will serye: Residence Com rciaf='`Other ' <br /> Number of living units: Numbie of bedr �• a' - f <br /> Character of soil to <br /> ' Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. El " Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t. <br /> LEACHING LINE s ❑ No. & Length of lines Total length/size <br /> FILTER BED t ❑ Distance to nearest: Well Foundat Property Line <br /> , ti7 R ± <br /> SEEPAGE PITS I I Depth Size Number <br /> ` ClDistance to nearest: Well Foundation Property Line <br /> SUMPS f - <br /> DISPOSAL PONDS L ❑ <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 s ant's signature certifies the following: "I certify that in the performance of the wI shall not <br /> ork for which this permit is issued, <br /> employ any on in such nner is to become subject to workman's compensation Eawa of California."Contractor's hiring ar sub-contracting signature <br /> certifies the flowing:"I ce ify 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 California,", <br /> r � <br /> The appli ant mu c all requi in Co tete d side. <br /> Title: '� Date: <br /> 'Signed X <br /> J2 OR DEPARTMENT USE ONLY <br /> Date <br /> f, Area Ct <br /> Application Accepted by ! <br /> A&AA4 /Z-/7 Data <br /> Pit Grau olnepection by date — Final Inspection by <br /> Additional Comments: $ _ <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services _ �- <br /> I 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 `� [ <br /> { <br /> FEE AMOUNT DUE AMOUNT REMITTED I K RECEIVED 9Y DATE PERMIT"NO. <br /> INF �� 3 <br /> rEK13-24(REV.IIM5) WE <br /> p <br /> I EH 14.15 <br />