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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �q d <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. 549 d l 2 and the Rules and Regulations of San <br /> Joaquin County Public Health S ry ces. <br /> �Job Address 1./O � � City_ Lot Size/Acreage <br /> 1 Phone <br /> Owner's Namge2a �"�"�""�" — Address <br /> f �o � a-aL ZS�Z z6�-S/� <br /> , r r <br /> Contract <br /> Address O License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out M Seoring Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER D Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL--PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Wel! Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Mariteca Dia. of Well Excavation <br /> I <br /> Specifications- <br /> f.l <br /> Domestic/Private ❑ Gravel Pack Type of Casing__C7 Tracy Type of Graut <br /> i'I Public 1-1 Other 11 Delta Depth of Grout Seal <br /> I I Irrigation —_Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H,P. State Work Done <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter ller Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I EPAIR/ DDITION DESTRUCTION i I (No septic system permitted if public sewer is A <br /> available-within 200 feet.I- <br /> Installation will serve:- Residence Commercial,___ Other r _/ <br /> Number of living units: Ie Number of becir o s - L� -}- <br /> Character of soil to a depth of 3 feet: —Water table depth <br /> �_ r <br /> SEPTIC TANK ❑ Type/Mfg Capacity� No. Compartments <br /> ii PKG. TREATMENT PLT.EIMethod of Disposal <br /> Distance to nearest: Well Y foundation Property Line l / <br /> LEACHING LINE j� No. & Length of lines <br /> Total length/size _x z <br /> ' FILTER BED ❑ Distance to nearest: Well� Foundation �� Property Line s t <br /> I SEEPAGE PITS Depth J -Size Number - <br /> Foundation <br /> SUMPS Cl Distance to nearest: Well r -( Property Line - <br /> DISPOSAL PONDS ❑ - R - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with-San Joaquiri county ordirnaiices,'state laws, and <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 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 sub`-contracting.signature <br /> certifies the following: "f 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." <br /> The applic must call f 11 r uired inspections. Complete drawing on reverVP _ <br /> 'dem `J t a <br /> _ Date: 4 Z i55igndTitle: - <br /> FOR DEPART ENT USE ONLY 6 <br /> Date �� Area <br /> Application Accepted by !, <br /> Pit or Grout Inspection by <br /> Date Final inspection by Date T X13 <br /> ` Additional Comments: <br /> f1 <br /> I 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, Stko, CA,95201�, � <br /> FEE ! <br /> G <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE <br /> PERMIf'N0. <br /> 61• EH 13.24 4REV.I/r SI 47 I-L' V i � f7 <br /> EH t4 le <br /> f <br />