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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 ISSUID <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 trade in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and RegulationB of San <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address <br /> Owner's Name Address Phone <br /> License No., Phone £• <br /> Contractor Address <br /> TYPE OF WELL/PUMPt NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl out of Service Well ,❑- <br /> Monitori_ g'Well <br /> PUMP INSTALLATION•-❑»,_ _SX ❑STEM-REPAIR, OTHER ❑ <br /> C.7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES {- DISPOSAL,FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 3 OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL -_ _PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> .C] Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t <br /> Ca Domestic/Private— ❑ Gravel Pack C] Tracy Type of Casing_ Specifications <br /> I'l Public' [I Other :F 1 Delta Depth of Grout Sea{ Type of Grout <br /> I I i Irrigation Approx. Depth 1 17Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. --State Work Done <br /> Sealing Material & Depth-,_ <br /> Well Destruction O Well Diameter— <br /> +.. � <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRlAODITION ! I DESTRUCTION hI IN septic system permitted it public sewer is r ' <br /> available within-200-feet.I <br /> Installation will serve: Residence_ commercial Other ~, 4 '• �; <br /> II` Number of living units: Number_of'bedrooms <br /> Character of soil to a depth.of 3 feet: '` �f � <br /> Wafe table-depth <br /> ;SEPTIC TANK `D''Type/Mfg > �^ ta1� Capacity No. Compartments <br /> PKC. TREATMENT PLT.❑ A.- �` �' Method of Disposal <br /> 14 Distance to nearest: Well t Foundation r Property Line <br /> I qty � <br /> LEACHING LINE Cl No. 6 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation _..�._Property_Lins <br /> SEEPAGE PITS I l _Depth Size Number <br /> SUMPS �Llf Distance to nearest: Well -- Foundation Property Line <br /> DISPOSAQLPONDS f ❑ <br /> I hereby certifyAhat I have prepared this application and that the work will tie done in.accordance with.San Joaquin county ordinances. state laws ,end <br /> t rules and reg dations of the San Joaquin Countyk. - <br /> t4l Home owner�r licensed 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 person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature'. <br /> I certifies=he 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 /> tionelaws of Californis." -. ! <br /> �e applicant must call for aH required.inspections. Complete drawing an reverse side. s <br /> r <br /> Signed ;y Title: Date: } <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> I Additional Comments: - <br /> Applicant—Re all copies�to: San Joaquin County Public Health Services �"` ��"` '"-•" <br /> Environmental Health Permit/Services <br /> "A 445,N <br /> 5,N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> s <br /> CK <br /> IFEENFO �+T DUE YAMOUNT REMITTED CASH RECEIVED BY DATE ' PERMiT N0. <br /> . EH43.24IFIEV6 i/a <br /> -.. -. <br /> EH 14m26'_ <br />