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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br />` t 445 N SAN JOAQUIN, PHONE (209)468-3420 A '_j _147 <br /> 1 P 0 BOX 2009, STOCKTON, CA 95201 REciFIVIE <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> o e r z 6 1992 <br /> i <br /> SAN i0Aomplete in Triplicate) PUS-11CH A - CC}t;NTY <br /> (C <br /> Application is hereby made to San Joaquin County for a permit to construct and/or 1nstal1 f.)(yV� re e c '#its F�^ This <br /> I, <br /> application is made in compliance vith Ban Joaquin County ordinance No. 549 and 1862 and the Rules ar36���thid3j$I�aflSan <br /> 6 <br /> Joaquin County Public Health Services. - <br /> Job Address • City Lot Size/Acreage <br /> Owner4Name Address Phone <br /> { �,� / <br /> ContraAddress ��• ense No. 3Z _ Phone <br /> I TYPE NEW WELL ❑ WELL REPLACEMENT DESTRUCTION o Out of Service Well Gl <br /> I <br /> Monitoring Well, C7 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINESi, V3 , i DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL.' OTHER WELL PITS/SUMPS k <br /> 1 <br /> INTENDED USE ,, i TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> N <br /> - � y ` ' Dia.of V+leII Casin <br /> C1 industrial ❑-Open Bottom ._❑ Manteca Dia of Well"Excavation - g 1 <br /> ( -9�estiG/Private L-1Gravel Pack L3 Tracy Type of Casing_ Specifications <br /> I <br /> I'1 Public 1-1 Other (�"Delta """ Depth of Grout Seal Type o1 Grout # <br /> I I Irrigation _Approx. Dep ll'IsEaslornt �-, Surface Se Installed by I <br /> Repair Work Done L7 Type of Pump _' -H.0. ' State Work Done I <br /> Well Destruction ❑ Well Diameter _45, --Sealing-Material t& Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is" <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial_ Other t y <br /> Number of living units: Number of bedrooms <br /> f Character of soil to a depth of 3 feet: Water table depth <br /> t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal j <br /> I <br /> ' Distance to nearest: Well Foundation Property Line " r <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundati6h " Property Line <br /> SEEPAGE PITS 11 Depth Sire Number :'1 <br /> SUMPS CI Distance to nearest: Well Foundation'° Property Line t <br /> k ✓,f <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 - 4 - <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 sh"ell not <br /> ..� I mpioy <br /> person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting"signature <br /> cartifies the following: '1 certify that in the performance of the work for which this permit is issued, I aha)!employ persons subject to wo►kman's'compensa <br /> I tion laws of California." <br /> The applican m II r all required ' coon Cc late drawing on rover /siide�: f <br /> Signed Title: Date: <br /> -- -.__- - OR DEPARTMENT UeE#ONLY <br /> Apjijicatiari Accepted by T ~� .T .Date Area 2 /r� <br /> Pit or Grout inspection by Date Final Inspection by ' Date ` <br /> i <br /> Additional Comments: <br /> r <br /> Applicant - Return all 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 /> I FEE t r <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y )]ATE PERMIT N0. ' t <br /> 01 <br /> P EH 13-24INEV.kix$I <br /> EH 14-20 <br />