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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 /> 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> Job Address 4/Iti City s Lot Size/Acreage <br /> Owner's Name Address Phone <br /> 1 <br /> ConEratao 1 ' <br /> Address i e No. Phone ' <br /> TYPE OF WELL/PU EW WELL Ol WELL REPL CEMENT DESTRUCTION Cl Out of Service .Well ❑ <br /> . PUMPJN57AL Tf N_Ild� .�,, _ Y REPAIR ❑ AER ❑ Monitoring WellD]STANCE.IO_NEAREST; SEPTIC TANK LINES, OSAL FLD P. LINE <br /> FOUNDATION �AGRICULTHAr WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY F WELL PROBLEM AREA CONSTRUCTION SPECIFIC T 0 4S <br /> Cl Industrial pen Bottom ❑ Manteca Dia. of Well Excavation7 Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Publi 1-1 Other .nj Delta Depth of Grout Seal T pe of GroutF <br /> I ngation _Approx. i-I astern � -�S7ur�face 5e+rl Installed by <br /> Repair Work Dane (J Type of Pump � P' —��.r _ State Work Dona \ a <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth=�ft <br /> + Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I I DESTRUCTION i I (No septic system permitted it public sewer is <br /> available 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 tagle depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity—_ No. Compartments f;V <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �h4. <br /> - Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size yV <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line v <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line 1 <br /> 4 <br /> DISPOSAL PONDS ❑ i r <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 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 workmen'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 persons subject to workman's compensa- <br /> tion laws of California." , r / <br /> The applicant mus all for allr uir coon Complete&rowing on r rse side <br /> Signed X Title: ' 4 Date: I. <br /> I <br /> F RDE R' ME SE ONLY / k <br /> Application Accepted by Date �'�� �� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date f <br /> Additional Comments: '� IS C(I <br /> ejuf ✓tPrr�y fa.td da a r•tg <br /> Applicant -' Return a 1 copies , 11 ..San;Jo� uin' Otun� ubft'C 4ealth Sery cesAS <br /> EnviYontnental Health Permit/Services <br /> �'445'N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> +. <br /> EE AMOUNT DUE AMOUNT REMITYE,D CSN RECEIVED BY DATE PERMI1 <br /> 1''NNO. <br /> . £H13.24 iAEV,r/Nsl a <br /> EH 114'26 <br />