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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL-HEALTH DIVISION f <br /> } - `��—�! <br /> 445 N SAN JOAQUIN, PHONE (209)468'3420 KM <br /> DY I <br /> P 0 BOX 2009, STOCKTON, CA 95201 -TTt1_ft6 D ,3 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 11 (Complete in Triplicate) <br /> to San Joaquin County for a permit rdinancenstruct No. 5498ando18628tall and theework Rules andein described.Regulations of Sans <br /> Application is hereby made. I <br /> application is made in eotttpliance'vith San Joaquin County y <br /> Joaquin County Public Health services. f <br /> City Lot Size/Acreage <br /> Job Address - - <br /> 5 r � _ Phone <br /> G Address' N <br /> Owner's Name 7][N "[�i��"'�� -133 <br /> s� License No. <br /> pr6GTess 28 <br /> ConIract0 WELL REPLACEMENT C7 DESTRUCTION•- -O <br /> TYPE Omant ber i" W-13 <br /> F WELL/PUMP: N�EWW ELL ❑ OTHER <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES �.---- DISPOSAL FLD. T <br /> DISTANCE TO NEAREST: SEPTIC TANKf���- AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> i <br /> WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 01 rM <br /> INTENDED USE TYPE OF aa'� Dia. of Well Excavation �'�� <br /> ❑ Open Bottom ❑ Manteca <br /> C'] Industrial - � Type of Casing- <br /> ['.I Domestic/Private ❑ Gravel Pack. ❑ Tracy <br /> " ClOther n Delta Depth of Grout Seal <br /> i'1 Public Surface Seal Installed by <br /> I I Irfigation --Approx. Depth l I Eastern ,. State Work Done <br /> of Pump �-- <br /> H.P. <br /> Repair Work Done LJ Type Sealing lrlaterial & Depth <br /> W ❑ well Diameter! <br /> Well Destruction <br /> Filler Material & Depth <br /> Depth <br /> systemE4 <br /> TYPE OF SEPTIC WORK: NEW WSTALLATION l I ADDITION I 1 DESTRUCTION i l availablerw thin 200 feat��ed if public sewer is [ � <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. compartments <br /> pe/M <br /> ❑ Type/Mfg Capaeity_�----- <br /> SEPTIC TANK ��. Method of Disposal <br /> PKG. TREATMENT PLT.ClProperty kine � — <br /> Distance to nearest: well Foundation�.�— (\�\ <br /> Total length/size V <br /> LEACHING LINE ❑ No. & Length of lines Foundation ' Property Line <br /> FILTER BED n Distance to nearest: Well <br /> Number <br /> SEEPAGE PITS 11 Depth <br /> Size T <br /> SUMPS Ll Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application <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 paws of once of the work for which this perm-[is issued, 1 she 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: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa <br /> tion laws of California." <br /> The applicant t call for ail ukred inspections. Complete drawing on reverse side. <br /> r Title: Date: <br /> Signed <br /> FO DEPARTMENT USE ONLY �� — �� r� <br /> _. Date Area <br /> Application Accepted by <br /> Pit or Grout inspection by Date�-- <br /> Final inspection by De[t <br /> t f <br /> ! �l <br /> Additional Comments', <br /> Applicant - Return all copies to: Environmentaln Jotquifi oHealth permit/Services <br /> unty 1 lie Health vices <br /> e 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED x <br /> CK RECEIVED BY DATE PERMIT N0. <br /> INFO 0 <br /> . EH 13.244REV,t/155) S / .- <br /> EH 14.26 r <br /> i <br />