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SAN JOAQUIN COUNTY PUBLIC -HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> ;1 P O BOX 2009, STOCSTON, CA 95201 <br /> I <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 vork 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 Sperv1'ees��] <br /> Job Address �r �`� Ir'+'�`—� �Y` �`'s------ City Lot Size/Acreage <br /> Ow of Nbame _ Phona <br /> /� , � y <br /> Contractor dress _q4_JIiNo. ` Phone St��vl <br /> TYPE OF WELL/PUMP: NEW Wttl ❑ WELL REPLACEMENT . DESTRUCTION ❑ Out of-Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR p OTHER ❑ Monitoring Well a <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION] AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r' <br /> ti <br /> ] Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications <br /> i'i Pubtic Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation ____Approx, Depth t I Eastern Surface Sedi Installed by I <br /> Repair Work Done U Type of Pump H.P. State Work Don <br /> Well Destruction ❑ Well Dia Sealing Material & Depth A. <br /> Depth M77Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permittred if public sewer is <br /> available'within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms '. <br /> Character of soil to a depth of 3 feet: ) Water table depth <br /> SEPTIC TANK: ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line <br /> (LEACHING LINE Cl No. & Length of lines Total length/size f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line k <br /> f <br /> SEEPAGE PITS 11 Depth l Size Number { <br /> SUMPS LI Distance to nearest: Well Foundation . .,T Property Eine <br /> DISPOSAL PONDS 0 ; <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San�J.aaquin-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 shell not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "I certify that in 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." t <br /> 1 <br /> The applican st call f ired in".cgons. Complete drawing on re rse side, # r <br /> Signed JIZ, Title: Date: <br /> 4 <br /> R D ART ( � <br /> 'Application Accepted by _ n�re L`LArea ZL- <br /> Pit or Grout Inspection by Date Final Inspection by _ Date !e o Z <br /> Additional Comments: ' t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 4545 N San Joaquin, P 0 Box 2009, Stkn, CA 95201CK A <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMITN0. <br /> • EEH 3-24 H 114.2i6IFt:V.fIK51 p 'Co �� 4)s <br />