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SAN JOAQUIN COUN-.'Y PUBLIC iMALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in 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 City Lot Size/Acreage <br /> r of <br /> A C <br /> Owner's Name r9l ✓IOAddress � Phone <br /> ;!Contractor Address ,G License N Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION o Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR K OTHER ❑ Monitoring Well C7 <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> '.,Domestic Iprivate ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications (` <br /> 11 Public Cl Other n Delta Depth of Grout Seal Type of Grout n <br /> I I Irrigation Approx. Deptpt+h_ I IIEEastern Surface Seal Installed by �s <br /> Repair Work Done I Type of Pump H.P. I State Work Dona �+ Q <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial__._ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3,feet: Water table depth £ <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments l� <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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, t 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 /> 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 Cali <br /> The ap nt must call r all required ctio Complete drawing on r ver a side. <br /> Signed X C_ Title: /� Date: <br /> am <br /> PARTMENT USE ONLY q <br /> Applicata n Accepted by .r:� s ,PAS_ is � _ Date Z"– 1 7— Area <br /> Pit or Grout Inspection by Date Final Inspection by ZIA Z Date f3 <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 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CKORECEIVED BY DATE PERMIT N0. <br /> INFO CASH �y <br /> b <br /> EH 13.2 INEV.t/Msl . [! Z�g r 1 <br /> #H t476 1i�` <br /> b <br />