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7 ` �j <br /> t �1 <br /> 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 ISSUED(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 i <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CountyAlleblic Healt Services. <br /> Job Address 2C)i City Lot Size/Acreage <br /> Owner's Name �v lrAddress a Phone J <br /> Contractor AddressLicense No. Phone <br /> TYPE OF.WELL/'PUMP: NEW WELL © WELL REPLACEMENT m DESTRUCTION CI out of Service Well ❑ � <br /> -PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well Ll f <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL. PITS/SUMPS_t___ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> FI Industrial 0 Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications r <br /> . i 11 :blit CIOther I1 Delta Depth of Grout Seal Type of Grout <br /> 1niS7atron Approx. Deptb I Eastern Surface Seal Installed by <br /> 'pair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth <br /> Depth g Filler Material b Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIWADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other a - <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of-3-feat: - Water table depth <br /> SEPTIC TANK. 1 ❑ Type/Mfg Capacity No. Ct <br /> PKG. TR 3 TMENT PLT.❑ a Meth sal } <br /> D21istance to nearest: + ` Well r Foundation Property Line `�' V D <br /> !f r 992 <br /> �. <br /> LEACHI'NG LINE ❑ No. & Length of lines Total length/s <br /> l <br /> FILTER BED E-) Distanceto nearest: Welt Foundation urn a Trr <br /> ENVlR <br /> SEEPAGE PITS 11 Depth r Size Number , <br /> SUMPS „^ LI Distance to nearest: Well Foundation Property Line <br /> * —DISPOSA-CPONDS -e'01-4 r; F" *� ! f �► �.. .- - r t }�...... �,n <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 46ulations of the San Joaquin County _ <br /> Home owner orlicsrisa�aganfa signatu►e certcertifi�s the following'"I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any persovn ' <br /> ' uch manner as to become subject to workman's compensation taws of,California:" Contractor's hiring or sub-contracting signature <br /> certifies thqtt <br /> 'I certify_that in the performance of the workfor which ChidpermitA issued, I.shall employ-persons.subject-to-workman's compansa,tion laws " <br /> The appliccall for all to ed inspecti . Complete drawing on to rs ba. <br /> Signed X Title: Date: -7 <br /> rOR DEPARTMENT USE ONLY <br /> Application Accepted by — Ca.� Il& - �T• ,,_.. Date 7 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional-Comments: - — <br /> Applicant Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445-NrSan Joaquin, P o Sox 2009, Stkn, CA 95201 <br /> FEEr INFO AMOUNT DUE AMOUNT REMITTED CK ECEIVE BY PATE PEFiM17NO. <br /> . E H 13-21 111EY,w/x 51 <br /> EH 11.2E r <br />