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�t <br /> 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 /> k application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> fE Joaquin County Public Health Services. <br /> at�D.lob Address V w 1!� � City Lot Size/Acreage <br /> } <br /> O n is Name Address Phone <br /> t � Q 111 <br /> actor MdonrV1f Ne <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT (7 DESTRUCTION ❑ Out of Service Well ❑ <br /> C PUMP INSTALLATION O SYSTEM REPAI OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I <br /> I) In ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f stic/Private Ci Gravel Pack 11 Tracy Type of Casing_ Specifications <br /> 1"I Public 1.1 Other f 1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx,;Dept 13 stern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Da _ <br /> Well Destruction © Well Diameter Sealing Material & Depth <br /> i Depth ' Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 (No septic syste Permiltei if public sewer is <br /> V R available within 00 feet.) <br /> Installation will serve: Residence Commercial_ Other } <br /> Numberof living units: Number of bedrooms <br /> l, �. . <br /> Character_of`soil.-to-e depth;ot 3 feet - _....-.._--__. . _. i ..1 _i0t Water—table depth �} <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compare nts <br /> PKG. TREATMENT PLT, ❑ Method of.Disposal <br /> Distance to nearest: Well Foundation Property Line t Fm <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED C1 Distance to nearest: Well Foundation Property Line <br /> rref <br /> SEEPAGE PITS 11 Depth f Sire Number r ; <br /> SUMPS LI Distance toy nearest: Well Foundation Property Line ►l ��`' ¢ �""� \" <br /> DISPOSAL PONDS ❑ h `� <br /> I hereby certify that I have prepared this application and that.lhe work will be donen`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 isignature cenifies the foilowin I certify that in they t r <br />' f3� ' Y performance of-tht wo�ich 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.�,CSntractor's hiring or sub-contracting signature , <br /> f certifies the following: " certify at in the performance of the work for which this per it.m.issued,Fii iI employ persons subject to workman's compensa- <br /> tion laws of aliforn! ." y r. <br /> ,. moi. _t t � <br /> The applic ' t ca or a rred i coons. Complete drawing a raver ide.: <br /> Si a <br /> Title: Data: <br /> OR pEPARTMENT USE ONtY <br /> Application Accepted by M1 Z <br /> Date Area <br /> Pit or Grout Inspection byDate Final Inspection by Date �� <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 O Box 2009, Stka, CA 95201 <br /> FEE AMOUNT DUE A OUNT REMITTED Cx <br /> INFO RECEIVED 8Y PATE PERM17'NO. <br /> . EH 13.24[REV.r/M5) g- <br /> H 14.2a r <br /> i <br />