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AF <br /> SAN JOAQUIN COUNTY ,PUBLIC HEALTH SERVICES <br /> ENVIRONMMAL 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 /> (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 L Citya7o Lot Size/Acreage <br /> wn is Name L __ Addresses Phone <br /> on �cTSr Nor= Phone r31 <br /> TYPE OF WELL/PUMP: # NEW WELL ❑ WELL REPLACEMENT F1 f �� • dESTRUCTION .❑. Out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 0\ <br /> Monitoring Well <br /> ; '� <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL,FLD,- PROP. LINE <br /> f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> ❑ Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia"of Well Casing <br /> Domestic/Private ❑ Gravel Pack El Tracy Type of Casing. ,Specifications <br /> I'I Puhiic !-1 Other. 171 Delta Depth of Grout Seal Type of Grout- <br /> + I Irrigation — Approx. Oep I I stern Surface Seal Installed b <br /> RepairlWork Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 5 Depth �f`r ` <br /> Depth Filler Material b Depth ~`7 ; W J4f <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION E I DESTRUCTION I I INo septic system permitted if public sewer is <br /> Nz } available within 200 feet) <br /> Installation will serve: Residencq_ Commercial— Other --- <br /> Number of living units: -" Number of bedrooms `� t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity ` ��lo. Compartments ` <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl, No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number } <br /> SUMPS LI Distance to nearest: Well Foundation . _ Property Line — <br /> DISPOSAL PONDS ❑ <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 nor as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: '9 ce fy that z n th gerformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Tawe of if <br /> The applicant st II for all r i pecti Complete drawing n rev r side. <br /> t <br /> Signe X Title: Date: <br /> i <br /> R PARTMENT USE ONLY t j <br /> Application Accepted by t'71�=a` i I Data al — Area d 7 r1 <br /> l <br /> Pit or Grout Inspection by Data Final Inspection by Data <br /> Additional Comments: <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 /> E <br /> FEE <br /> INFO AMOUNT Dt E AMOUNT REMITTED CASH CK A RECEIVED BY DATE PERM i7'NO. <br /> . eH 13-24IREV.t/KSI90 <br /> �� <br /> EH 14.75 (� (� <br />