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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 98201 <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) _ <br /> in <br /> Application is hereby trade,toASan`Joaquin coountuinoCounr a ty Ordinsncemit to nNo 5k9struct 8ando1862sand thetall eHules audwork eRegu]ationsdof San <br /> s <br /> applicntiott is glade in compliance ' <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> I Job Address ? "7 <br /> r 1 7 LC <br /> Phone S <br /> Owner's Name <br /> ti <br /> S 13 Phone S- <br /> Contractor <br /> �`r75 Address - License No. <br /> TYPE Of WEL'LIPUMP: NEW WELL WELL REPLA MENT n DESTRUCTION ❑ Out of Service'Well L7 <br /> OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 130 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> /10t) SEWER LINES Dl PO A - PROP. LINE1. _ <br /> O <br /> FOUNDATION AGRICULTURE WELL 0 HR rLQ� — PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .0 J <br /> Dia. of Well Casing `,l <br /> n Industrial C) open Bottom C3 Manteca Dia. of Well Excavation� 3 O V� <br /> Tracy Type of Casing_ V Specifications.- <br /> Domestic I Private <br /> pecificationsDomesticIPrivate 1(Gravel Pack. � Type of Grout W <br /> I:I Public I:1 Ot er n Delta Depth of Grout Seal <br /> I i Irrigation /OApprox. Depth I I Eastern Surface-Seal Installed by_ <br /> State WorkDone <br /> Repair Work Done U Type of Pump <br /> H P ' <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> DeptFi l�Cj- Filler Materiel& Depth <br /> TYPE OF SEPTIC WORK: NEW c system perm <br /> INSTALLATION I I REPAIRIADDITION I V DESTRUCTION i I ahvailabPO soelwithin 200 feetilt d if p61iC sewer is jh <br /> Installation will serve: Residence;l Commercial— Other <br /> t .. <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet:L No. Compartments ' <br /> SEPTIC TANK. [3Type/MtgL Capacity Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linea. = , <br /> Total length/size <br /> FILTER BED I-] Distance to nearest. Well Foundation 'Property Line <br /> i <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ F <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 /> F 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 /> person in such manner n to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any <br /> certifies the perso inn: certify that s 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 applican st call for all requir inspections. Complete drawing o verse aid <br /> Signed <br /> Title: Date: Z <br /> FOR DEPA MENT USE ONLY ' f <br /> Application Accepted by <br /> Date In��-qZ Area-----(2 <br /> li pate Final Inspection by Date <br /> Pito GFQU Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> I Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> F FEE CK RECEIVED BY DATE PERMI '141 0 <br /> FEEINFO AMOUNT DUE# AMOUNT REMITTED CASH <br /> 9,. EM 17-24 IREY.I�n 5) 4 <br /> EH 11.16 <br />