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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby Stade to Sam Joaquin County for a permit to construct and/or,install the Mork 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 7 x City o!V4 iA Lot Size/Acreage <br /> Owner's Name Address Phone <br /> Contractor"" - 4� Address T License Nqp Phone` <br /> TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL --.PITS/SUMPS I <br /> INTENDED USE � TTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> yn i1ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation__ - Ria. of Well Casing I <br /> C.) Domestic/Private ❑ Gravel-Pack� • L7 Tracy Type of Casing_ Specifications <br /> F1 Public [) Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I Ifrigation —..Approx. Depth t I Eastern t Surface Seal Installed by i <br /> Repaair-W6-rV-Dafv "'t]-- Type of-Pump State Work Done <br /> I-M-,TSealing Material & Depth <br /> Well Destruction`-^Q Well Diameter <br /> ' Depth Filler Material & Depth <br /> TYPE 0F.SEPTIC_W0RK: NEW INSTALLATION I i REPAIR/ADDITION DESTRUCTION 1 I INo septic system permitted if public sewer is <br /> available within 200 feat.I <br /> Installation will serve:, ;Residence Commercial Other <br /> Number of living units;' Number of bedrooms 3 <br /> ' ,} fl �. /� _Water table depth <br /> Character of Boli to a bepth of 3 feet: . ,ftJ b - <br /> SEPTIC TANK. -.0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PtT'.❑ Method of Disposal {� <br /> Distance 10 nearest: Well Foundation Property Line \' <br /> p*`l0 �FT Total Ian <br /> LEACHING LINE' i ❑ No. & Length of lines gth/si& <br /> r fk <br /> FILTER BED -K-Distance 2o-nearest: Well/UVft Foundation fes!'`"• _ Property,, <br /> _L+ne <br /> e SEEPAGE PITS I I Depth Sire Number <br /> SUMPS t l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ID r <br /> I hereby certify shat 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 orlicensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ'any.per`son"in such manner as to become subject to-workman's compensation taws of California." Contractor's-hiring or sub-contracting signature r <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 workmen'sc ompensa <br /> tion laws of California." <br /> I The applicant must call for a re fired ins ctions. Complete drawing on,reverse side. <br /> Signed X Title; _d'9+_t•^ _.— Date. _#- <br /> POe <br /> DEP I <br /> Applica`tion'Accepted by <br /> Date Finel'In06etion by Oat <br /> Pit or Grout Inspection'by � - � <br /> Sig <br /> Additional Comments 1 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services e <br /> Environmental Health Permit/Services <br /> ry 445 N San Joaquin, P_O Bax 2009, Stkn, CA 95201 R <br /> - -`FEE AMOUNT DUE - AMOUNT REMITTED GK RECEIVED SY, _ PATE__ _.PERMIT'NO.-. 4 <br /> z INFO — <br /> . EH 13-24MEV.tine1 <br /> #H 14-25 aJ <br />