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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 0 Box 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <br /> (Complete in Triplicate <br /> Application is hereby made to Sal'Lquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coap'liance,with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services`. h <br /> J <br /> Job Address <br /> 3 e I Lot Size/Acreage <br /> r <br /> Owner's Name LAQ Address ' Phone C W <br /> Contractor —Address License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> 1. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well ❑ <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 <br /> ❑ Industrial ❑ Open Botiom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing <br /> D Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications \ <br /> I'1 Public C1 Other 11 f 1 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation Approx; Depth II Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pum p H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material !< Depth <br /> Depth 1 Filler Material is Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation,will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feat:l Water table depth <br /> SEPTIC TAN I 5;KMe'Typa/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE tR?- No. & Length of lines s- Total length/size <br /> FILTER BED n Distance;to nearest: Well Foundation Property Line <br /> 'I <br /> 1 <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS C3 Distance'to nearest:, Well Foundation Property Line <br /> = `+• may. . <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared'thi1:application and that th-a 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 manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "i certify that in"tile performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." - ,.J. <br /> The applicant all for all required inspections. lZornplele drawing on reverse s 8e4 <br /> igned K Title- Date: <br /> s <br /> FOR DEPARTMENT USE ONLY " <br /> Application Accepted by Date Area <br /> i � �t <br /> I Pit or Grout Inspection by I . Date Final Inspection by ate ' <br /> 1 <br /> i Additional Comments: <br /> Applicant Return a,41 copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUN RUE AMOUNT REMITTED CASH <br /> :176 <br /> RECEIVED BY 7E PERMIT'NO. <br /> INFO <br /> . EH 13.24[f1EV.1 i n Sl t/" Lfr f02 <br /> EH 11.26 ' <br />