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SAN J,.1QUIN COUNTY PUBLIC HEALTH �ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOA UIN, PHONE (209)468-3420 <br /> Q <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1! (Complete in Triplicate) <br /> Application is hereby made,to San lJoaquin County for a permit to construct and/or install the work 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 Services. 2 <br /> r I GGA 4�1� ,�QGA� ,(/r`D�. �� Lot Sixe/Acreage „T <br /> Job Address ,. City <br /> f' <br /> Owner's Name�f t^D Address[! �l E• �aw <br /> � ✓ Phone v�� <br /> Contractor <br /> 't { t' Address 2 Phone <br /> TYPE OF WELL/PUMP: NE ELL El <br /> REPLACEMENT Cl OESTRUCTfON Out of Service Well <br /> PUMP INSTALLATION C7 SYSTEM REPAIR <br /> OTHER CJ Monitoring Well <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 PEGFICATIONS <br /> Cl Industrial C] Open Bof'om 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Tracy Type of Casing_ D Specifications. <br /> EI Domestic/Private C] Gravel Pack Type of Grout <br /> i'1 Public t 1 Other � CS Delta Depth of Grout Seal q <br /> i I Irritation _.Approxi Depth I I Eastern Surface Seal Installed by <br /> Repair Work pone U Type of Pump <br /> H. State Work Don <br /> Sealing Material Depth / �5•57 <br /> -14 <br /> Well Destruction Well Diameter� <br /> Depth Filler Material & Depth o <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I OESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> 4 Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK TypelMfg Capacity No. Compartments {A <br /> C7 Method of Disposal <br /> PKG, TREATMENT PLT. <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total lengthlsize <br /> ' FILTER BED ❑ Distance Ito nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sizes Number <br /> SUMPS 0 Distance' tonearest: Well Foundation Property Line <br /> DISPOSAL PONDS C] <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, andIle <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 She work for which 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." Contractor's hiring or 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." <br /> i The applica st c or all required inspections. Complete drawing on reverse s 6-79-9 <br /> Signed Title: Date: <br /> 2-- -- <br /> f i FOR DEPARTMENT USE ONLY <br /> t Application Accepted by Date Area <br /> Pit or Grout Inspection by Data Z Final Inspection by Date 2 <br /> Additional Comments: ; <br /> l Applicant - Return all copies to: San Joaquin County Public Health Services <br /> f Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> fEE AMOUNT DUE AMOUN�RE IT-TED CK H RECE1 D BY DATE PERMIT'NO. <br /> INfO <br /> - <br /> EM 13'24 IREv.I/n 5l D,��,. <br /> �- gz <br /> EH 1420 <br />