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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> h P 0 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 /> application is trade In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. //t� <br /> Job Address > / � S 9 158 City Lot Size/Acreag V <br /> Owner's NameC Address Phone <br /> Contractor I-- Address `• cense No.4bC Phone <br /> I TYPE OF WELL/PUMP. NEW WELL IDWELL REPL CEMENT Cl DESTRUCTION 0 Out of Service Well Cl <br /> PUMP INSTALLATION E) SYSTENLREPAIR-1=1 .` OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES j DISPOSAL FLO. a PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL t PITS/SUMPS <br /> INTENDED USE TYPE OF WELLI, PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom i ❑ Manteca Dia. of Well Excavation ' 'l Dia. of Well Casing <br /> f-1 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ ' { Specifications <br /> C1 Public I-1 Other n Delta Depth of Grout Seal } Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Sedl Installed byk ` <br /> Repair Work Done L3 Type of Pump f H.P. -',_._, .State Work Done <br /> Well Destruction O Well Diameter Sealing Material'& Depth I <br /> Depth <br /> j Filler Material'& Depth t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION uBGPK1R/ADDITION I I DESTRUCTION t I (No septic system permitted if public sewer is <br /> 4 - M I available within 200 feet.) (� <br /> Installation will serve: R Idence Commercial Other t <br /> a <br /> Number of living units: 77 Number ofroomLs�—• <br /> Character of soil to a depth of 3 feet: ( T Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 7TO&I refer .C.#p,acity ArdfiM No. Compartments <br /> PKG. TREATMENT PLT. ❑ ` ? r Method of Disposal ` <br /> Distance to nearest: Well Foundation Property Line <br /> 11 JbLtl <br /> LEACHING LINE o. & Length of lines __ Tot�I length/size <br /> i FILTER BED ❑ Distance to"nearest: Well Foundation _ Poperty Lina. , <br /> SEEPAGE PITS I 1 Depth I Size k Number <br /> SUMPS St nee to nearest; Well Foundation�p e� Property Line <br /> DISPOSAL PONDS <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 i ) <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of Is work for which this permit is issued, I shall not <br /> Z�mpany person in such nner as to hecoine subm to w. kman's_compensationlaws_of_Caiifor�- Contractor's hiring or sub-contracting signature <br /> t otlowing: "I rti hat in thepe man e h for which this permit is issued, I shall employ persons subject to workman's compensa-s of o is.lican mus all f alt req rye to pie drawing n r v eside. <br /> itl Date: <br /> i FOR-DE TMENT USE ONLY,':' <br /> fy�P C=� /� i <br /> Application Accepted by Date c � �x ;A Area <br /> Pit or Grout Inspection by Date Final Inspection by Date a <br /> Additional Comments: <br /> App3•icantw--Return—wl-1 copies^to:—San Joaqui'n'-County Pu151'ie—Hhal'Yh Se'rvices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin Box 2009, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDtK RECEIVED 9Y DATE PERMIT'N0. <br /> NFOEHl3-I4{AEV.rixs) Op <br /> EM 7428 <br />