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� III �.�„�.�. .•r <br /> f 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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> i <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> t application is made in cwtpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servics. <br /> Job Address <br /> D :III eCity 7 of Size/Acreage rb <br /> 11 <br /> 113 <br /> Owner's Name Address _ t t 1"-� Phone <br /> 44 <br /> �'" Mell <br /> ConfrTpr - Iv`-' Adtff � ftSnPhone <br /> t .. <br /> TYPE OF WELL/PUMP: i� NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0Out of Service Well ❑ <br /> PUMP INSTALLATION Adm SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> I <br /> 'DISTANCE TQ NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION . AGRICULTURE WELL OTHER WELL PITS/SUMPS . <br /> INTENDED-USE;: '- 'TYPE.GF-WELL��PROBLEM AREA.r,CONSTRUCT.ION-SPECIFICATIONS. _ <br /> O Industrial _❑`open-Bottom ❑ Manteca Dia. of Well Excavation _ Oia. of Well Casing <br /> omestic/Private ❑ Gravel Packf ❑ Tracy Type of Casing_ . Specifications <br /> r ` fotSalI'I Pubc C1 Other Delta' Depth ---Type f-Grout= <br /> I I Irrigation „f pprox. De th I I astern Surface Seal Installed by <br /> Repair Work Done U 7ype:�of Pump H.P. — <br /> _ State Work Done <br /> Weil Destruction O Well:Diameter ++ Sealing Material & Depth <br /> Depth �4UjT _ Filler Material A Depth \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is <br /> # avaiiabie 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 /> r SEPTICJANK ❑ Type/Mfg - Capacity No. Compartments <br /> j PKG. TREATMENT PLT.0 II Method of Disposal <br /> - ' Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total lengthtsize <br /> ,I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS it Depth Size _ Number <br /> i <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O ail. <br /> - .-4-hereby-certify-that•1 have prepared.this-application.-and-that-the-work will-be-done-in.accordance with-San-Joaquin.county.ordinances;state laws;and- ti <br /> rules and regulations of the Sari'Joaquin County <br /> Home owner or licensed agent'ti 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 subcontracting signature <br /> certifies the following: "l 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." 'I <br /> The applic m st call foMdins ctions.,Complete drawing on rev r e side. <br /> M Signed Title:- pate: <br /> d" 1q4 <br /> I' I� <br /> I I F R DEPARTMENT USE ONLY �7 <br /> Application Accepted by I Date ` Area ' <br /> Pit or Grout Inspection by II� Date Final Inspection by 1 Date <br /> Additional Comments: a <br /> I <br /> Applicant - Return all copies to: 'San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE,` AMOUNT REMITTED CK RECEIVED BY R E PERMIT'N0. <br /> t INFO CASH 0/7 <br /> , EM 13-24 IREV.I/x 51 <br /> EH 14-n yl!t <br />