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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> I <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> DEC 3 11992- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) <br /> Applicat�T>�e WIQEfi 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 3,812 So o grrrG City SJkAl Lot Size/Acreage <br /> Owner's Name Address ✓� Phone J <br /> f CM44C�KAddress L License No.�Z�Phone q Z✓- <br /> Contractor Zc <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D Monitoring Well L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public I I Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth ll Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Weil Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION iNo septic system permitted it public sewer is <br /> available within 200 featJ <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms CA <br /> Character of soil to a depth of 3 feet: __­�-Water."tabie-depth <br /> SEPTIC TANK ❑ Type/Mfg _ _ Capacity-- No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 <br /> Home owner or licensed agent's signature Certifies the following: "1 certify that in the-performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature , <br /> certifies 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: ate:` <br /> FOR DEPARTMENT USE ONLY q <br /> Application Accepted by - . Date Area <br /> Exit or Grout Inspection by Date Final Inspection y�2 ate <br /> 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 O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. <br /> INFO 7[� CASH <br /> . Eli 1314 lttEV.i/x 5) i /, <br /> EH 14.16 00 <br />