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• SAN JOAQUTN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION "'En �" U <br /> 445 N SAN JOAQU IN, PHONE (209)468-3420 J U N 5 1092 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/HRVICES <br /> (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 /> 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 /> Job Address ' `�r City���Lot Size/Acreage <br /> Owner's Name <br /> Address �s�' _ �lQs.�—��� Phone ' <br /> Address\\% License No.O <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHER Ll Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing w <br /> Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing_. Specifications <br /> i'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout A"'VVV <br /> I I Irrigation p�i Approx. Deptht�,�I I Eastern urface S 1 Installed by <br /> Repair Work Done N614Type of Pump.ep ► H.P. 1 t � ---- State Work Done <br /> Well Destruction ❑ Well Diameter _]_ k Sealing Material & Depth <br /> Depth 261 Filler Material & Depth' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I Mo septic system permitted if public sewer is <br /> _ available within 200 feet) <br /> Installation will serve: Residence Commercial T Other <br /> Number of living units: Number of bedrooms e� <br /> Character of soil to a depth of 3 feet: Water table depth \ <br /> SEPTIC TANK - ❑ Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line n <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 1� <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 <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,Tahall'no'i <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 /> cenifies 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 /> The applicant <br /> must call for all required inspections. Complete drawl reverse side. a <br /> Signed X\ Title: Date: AV' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data � ^� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 5 <br /> Additional Comments: f <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 /> FEE]]p AMOUNT DUE AMOUNT REMITTED C <br /> INFFASH ECEIVED BY DATE PERMIT'yN�O. / <br /> . EH 112 (REV. <br /> EH 11.20 C� JJ <br />