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SANT JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <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 /> r (Complete in Triplicate) <br /> I <br /> Application is hereby mad <br /> e,to San Joaquin County for a permit to construct and/or install the work herein described. <br /> dof Sans <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 18b2 and the Rules and Regulations e/ <br /> Joaquin County Public Health8 vices. <br /> I; Lot Size/Acreage <br /> Joh Address <br /> L a �o f'/JC Ity I'?aC$ <br /> � Q <br /> Q' Address «.� �~ <br /> } I z`U p /Y•�$�iJ� f-61-of�s Phone <br /> �+ c� C <br /> Owner's Namer � <br /> ) �(• 2 A1,2� License No. s <br /> � v Phane <br /> /_AIW Address rv° <br /> Contractor WELL REPLACEMENT [ DLSTRUCTION Out of Service We31 ❑ <br /> NEW WELL ❑ OTHER ❑ monitoring Well ❑ <br /> TYPE OF WELtIPUMP: SYSTEM REPAIR ❑ .. <br /> PUMP INSTALLATION ❑ DISPOSAL SEWER LINES FLD. PROP. LINE <br /> �-^-- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK ------ AGRICULTURE WELL OTHER WELL <br /> TYPE OF W <br /> " FOUNDATION �-- <br /> WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> INTENDED USE �--- Dia. of Wel) Casing <br /> ❑ Open Bottom ❑ Manteca Dia, of Well Excavation <br /> Cl Industrial Specifications 1 <br /> Type of Casing_ <br /> [I Domestic/Private ❑ Gravel Pack 11 Tracy Depth of Grout Seal Type of Grout <br /> 11 Other I I Delta �r <br /> I'I Public Surface Seal Installed by <br /> I I Irrigation �_Approx. Depth 1 I Eastern grate or D no r4e y <br /> i of Pump ; H.P. <br /> +Repair Work Done U Typo ——�� Sealing Material & Depth <br /> }VIletf estruction Well Diameter _ -- <br /> + e / Filler Material Depth <br /> Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRlADDtTION l I DESTRUCTION I i INo septic sy tem permitted it pub+e sewer is <br /> Installation will serve: Residence.,____f <br /> Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: ) Capacity. _---- No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal • <br /> PKG. TREATMENT PLT.❑ Foundation Property Line <br /> Distance to nearest: Well <br /> Total length/size 1 <br /> LEACHING LINE ❑ No. & Length of lines r*�J <br /> FILTER BED t=] Distance to nearest: Well <br /> Foundation — Property Line -- <br /> i Size Number <br /> SEEPAGE PITS I k Depth property Line <br /> SUMPS LI Distance to <br /> nearest: Well Foundation �v <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, and <br /> rules and regulations of the San JoaquimCounty <br /> Home owner or licensed c�g ne gas�ofe certifies the ome subject lowing; "I the <br /> workman's:coythat in the mpensation taws 01 California."Contractor'sfhiring or sub-contracting this permit is eisignlatu�e <br /> employ any person <br /> the work for which this permit is issued, 1 shall employ persons subject to workman's compen <br /> sa <br /> certifies the following::"I certify that in the performance of - <br /> tion laws of California." <br /> The applicant m t�ap r all requir ins coons. Complete drawing on reverse 'do.��4 — —Q <br /> k Date: <br /> Signed Title: <br /> i u, F DEPARTMENT USE ONLY <br /> Date �� �~ res <br /> ` Application Accepted by <br /> Date <br /> r Pit or Grout inspection by <br /> Date�-- Final inspection by <br /> Additional Comments: <br /> �y _�, r Public Health Services <br /> Applicant - Return all copies to: San Joaquin County w <br /> Environmental Health Permit/Services -� `3­ <br /> 445 N.San,Joaquin, P-A..Box.2009, Stkn, CA 95201•"- <br /> 1 CK RECEIVED BY OATE PERMIT NO. <br /> t FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> • EH 13.24 IREV-I"S \ F® 00 <br /> EH 14.20 <br />