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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> I� (Complete in Triplicate) <br /> d <br /> Applicand ation is hereby Stade to Ban:Joaquin County for a permit to construct <br /> and/or ineand ttheRules work hereandin describeof Sens <br /> applicationro <br /> fa ads in compliancelrrith San Joaquin County Ordinance <br /> Joaquin county Public Health Services. <br /> City ) Lot Size/Acreage <br /> Job Address <br /> Phone <br /> ' Address <br /> wner's Name f,,� f I(��'� �• � 1 rt e o. w 1 Phone � <br /> ddre s <br /> TYPE OF WELL/PUMP. NEW WELL © WELL REPLACEMENT C1 DESTRUCTION ❑ Out Monitoring Well I <br /> PUMP kNSTALLATIO <br /> SYSTEM REPAIR OTHER 0 <br /> SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS yDia. of Well Casing <br /> is I dustrial ❑ Open.Bottom_,- 0 Manteca Dia. of Well Excavation Specifications <br /> L7 Tracy Type of Casing_ <br /> omestic/Private 0 Gravel Pack Depth of Grout Seal Type of Grout <br /> I'l Public [-1 Other C�1 Delta <br /> I i IrrigationApproxi;Dep I Eastern Surface Seal Installed by <br /> j H P State Work Done <br /> Repai�Work Done U Type of Pump n R <br /> Sealing Material & Depth ly�� <br /> Well Destruction ❑ Well Dig ete Filler Materiel & Depth <br /> yE?epih <br /> t lNo <br /> TYP£ OF SEPTIC WORK �;•NFW INSTALLATION f 1 REPAIR/ADDITION 1 i DESTRUCTION ; I avaiiablelwThin 206 permitted if public sewer is <br /> Installation will serve: Residence _.." Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depthbedrooms <br /> Character of soil to a depth of 3 feet: — No. Compartments <br /> SEPTIC TANK. 0 Type/Mfg N Capacity -- <br /> ,. Method of Disposal <br /> PKG. TREATMENT PLT. ❑ a <br /> # Property Line <br /> Dista ice to nearest,, » Wetl foundation Pe Y <br /> I � <br /> a µ` Total length/size <br /> LEACHING LINE D No. 8i Length of linea r Property Line <br /> FILTER BED n Distance to nearest: Well Foundation <br /> t <br /> l I Depth Size Number <br /> SEEPAGE PITS Property Line t <br /> SUMPS 0 Distance to nearest: Well Foundation r <br /> F f J I <br /> DISPOSAL PONDS <br /> ~ <br /> with San Joaquin county or <br /> I hereby certify that I have prepared this application and that the work will be done in accordance ordinances, state laws, ander <br /> rules and regulations of the San Joaquin County - <br /> t Home owner or licensed agent's signature certifies;•the follow ng; "I Certify that in the performance of the work for which this permit is issued, F shall not <br /> employ any person in such manner as to become s biect t6'vJorkman's compensation laws of California." Contractor's(tiring or sub contracting signature '? <br /> ¢ certifies the following: "I certify that in the pertormtce of the'workjfor which this permit is issued, I stall employ persons subject to workman's compensa- <br /> tion laws of California." 3/ <br /> The appli n4 ust cal r uired inspections. Complete drawing on side. --- <br /> 04& <br /> l91 <br /> t <br /> E � Title- <br /> r <br /> Sign I / <br /> F <br /> DEPARTMENT USE ONLY <br /> _ Date roe 1 <br /> Application Accepted by <br /> { Date - Final Inspection by <br /> Date <br /> Pit or Grout Inspection by � �• <br /> 7 Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P d Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE EAMOUNT REMITTED <br /> C�CASI#/ RECEIVED BY DATE PERMIT NO. <br /> INFO r r 0 <br /> _ EN t3.24 1REY.1/MSI t Q� <br /> A EH 14.26 <br />