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4 <br /> APPLICATION <br /> �L <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^ � <br /> ENVIRONMENTAL HEALTH DIVISION C . <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> � e <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT "EXPIRES 1 YEAR FROM DATE ISSUED `-" - <br /> (Complete in Triplicate) VCK2_ <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. r <br /> Job Address © + } 1 City Lot Size/Acreage <br /> .6 <br /> Owner's flame <br /> ' x Address r Phone <br /> License No. Phone <br /> Contractora,3��Address <br /> TYPE Of WELL/PUMP:MP: NEW WELL ❑ WEL�It AGEMENT Cl DESTRUCTION ❑ Out of Service 1Ie11 Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 5 Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f:] Domestic/Private El Gravel Palk* L Tracy�Y7ype of"Casing_ Specifications <br /> ("1 Public Cl Othern Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation ____..Approx. Depth , I I Eastern Surface Seal Installed by t <br /> r State Work Done _ <br /> Repair Work Gone Type of Pump H.P. <br /> . Sealing Material & Depth <br /> I <br /> Well Destruction D ell Diameter. • - <br /> Dept [ Filler Material'& Depth n <br /> TYPE OF SEPTIC WORK: NEW IN 'LLATION I 1 "REPAIR/ADDITION l I DESTRUCTION I No septic system permined if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Co ercial_ Other q <br /> r i <br /> Number of living units: Number of bedr _ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg� Cap c y No m <br /> Compartents <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Fou tion Property Line <br /> LEACHING LINE L� No. & Lel gth of lines Total length/size <br /> FILTER BED CI Distance to nearest: ell Foundation Property Line <br /> :{ p <br /> SEEPAGE PITS 11 Depth Sire _ Number i <br /> SUMPS LI Distancet Barest: Well Foundation Prope Line I <br /> DISPOSAL PONDS © f <br /> I hereby certify that i ha spared this'Application and that the work will be done in accordance with San Joaq county ordinances,'state laws, and <br /> rules and regulations of the Sen Joaquin County - -s' <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: "I canify that in ttie 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 /> Theapplicant must call for all re d inspections. Complete drawing on reverse side. <br /> Signed Title, A�,7 -- .. Date: I <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by <br /> ._:. Date —1—?�-` I Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> [ <br /> Additional Comments: /r , <br /> ,`� e �' � �� ��tG� '� - <br /> Applicant •- Return all copies to: San Joaquin County Public Health Services ��`� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASk RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> + EH 17-241ACV.vx5) - ua.,d e y�I <br /> EH 14.2a _ <br /> k [ <br />