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k <br /> 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 EgPIRES L YEAR <br /> FROM DATE ISSUED <br /> j (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 /> 1 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. <br /> aj= f41 i I r�d��D �' �t ity Lot Size/Acreage lj �� <br /> Job Address <br /> lYPhone <br /> Owner's Name ��--�� �r�t Address-_� f <br /> k License No. Phone <br /> Cnntractar Address ` <br /> TYPE OF WELLIPUMP: NEW ❑ <br /> PUMP INSTALLATION WELL WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ <br /> t OTHER Monitoring Well ElSYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP- LINE <br /> FOUNDATIAGRICULTURE WELL OTHER WELL- <br /> 7 <br /> ELL P17SISUMPS <br /> ON <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-] Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Specifications <br /> [7'pomesticlPrivate - ravel Pack ❑ Tracy Type of Casin 9-- Type of Grout <br /> I'I Pu rc Ch Other II Delta Depth of Grout Seal _ <br /> I rrivation __Approx.iDewh LI Eastern Surface Seal Installed by ` <br /> Repair Work Done 0 Type of PumH.P. - b State Work Done <br /> � — <br /> Well Destruction [3Well Diameter Sealing Material & Depth <br /> o <br /> Depth Filler Material & Depth Q <br /> I TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo avail septic <br /> s st m loot.) if public sewer is <br /> r <br /> Installation will serve: Residence Commercial— Other r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet-1 Water table depth <br /> SEPTIC TANK.. ❑ Type/Mfg Capacity No. Compartments <br /> Methot <br /> PKG. TREATMENT PLT. L1 f Cf ap-o <br /> Distance to nearest: Well Foundation Property tine <br /> - <br /> LEACHING LINE Cl No. & Length of lines _ Total tengthfsize <br /> f FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> .� SAN JOAQUIr! COL:NTY <br /> iJL�I_!t rtwN'_ ',; sV �D <br /> SEEPAGE PITS 11 Depth f Size Number rNVR&ME rt1-t-1 !Iw'i5E�1i'' <br /> SUMPS LI Distance.to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify 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 <br /> Home owner or lice d agent's signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I shall net <br /> employ any per such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> I ceniTias tho folly i : "I cenify that in the parlor once of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> I tion laws of Ca nia." ,I <br /> The applican t caEl f aN a Ired in omplete drawing on r er ids. <br /> r <br /> 1 Title: Date: <br /> Ik Signed X <br /> FOR DEPARTMENT USE ONLY / <br /> Area �c!(v <br /> f Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date �O QZ <br /> k <br /> Additional Comments; <br /> r <br /> Applicant - Return all copies to; San Joaquin County Public Health Services <br /> 1 Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE1AM;OEUNTDUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT'NO. <br /> INFO �^ S EH 13d41pEv.l�Ksi +� <br /> EH 14.28 <br />