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�� ..,._.. .-�-... � �-.ems--•-a,=--��..�- fir,, � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 <br /> 01` ENVIRONIMTAL HEALTH DIVISION <br /> , i 445 N SAN JOAQUIN,�,PHONE (209)468-3420 <br /> P O BOX 200b-,- ­ 'STOCSTON, CA 95201 <br /> PERMIT MIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County fora <br /> application is made in compliance with Ban Joaquin County constructmit to and/or <br /> yOrdinanceno. 549andatau eherein vork described. <br /> 1862and theRules andRegulationsof Sans <br /> Joaquin County Public Health Services. 1 <br />•,, Job Address r City t Size/Acreage <br /> Owner's Nama Address yea X_ <br /> Conttacto �.«`. Address -F 640 X l License Nc. �� phone RC1 <br /> TYPEAF WELL/PU P: <br /> A+! NEWW,ELL ❑ WELL REPLACEMENT DESTRUCTION �l Out of Service Well ❑ # <br /> t PUMP}INSTALLATION 0 SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> `'.&STANCE.TO NEAREST;,SEF IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE °a <br /> ,FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE 3 TYPE OF WELL PROBLEM.A4A:IPONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca-:r qif- of Well Excavation Dia. of We <br /> til <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing=' Specifications <br /> Il Public t El Other fl Delta-�. De th of Grout Seal R <br /> 4_ ;, ? e of Grout <br /> t I Irrigation. Approx. Dept l..l stern Surfac Seat Installed by <br /> L/ <br /> a� �,Repait.l!kork Done tS TV. ype,of•Pump a H.P, _ r.___ «�"State Work Do <br /> Well Destruction p Well Dia"e{er' Sealing'Material A Depth <br /> Dapth—~� Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION II DESTRUCTION..I.,I_fNo septic system permitted if public sewer is �J j <br /> available within 200 feet.) <br /> tnatallatian will serve: Residence— C mmercial_ Other = FL_t # <br /> Number of living units: Number of drooms "' ,ws "'""" � <br /> Character of sol)to a,depth of 3 feet: Water table depth <br /> SEPTIC TANK ! ❑ Type/Mfg Capacity x " No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> t ; Distance to nearest: Foundation Property Line <br /> LEACHING EINE � ❑ No. & Length of lines Total length/size s <br /> FILTER BED: [� Distance,to�:nearest; ell Foundation Property Line ` <br /> SEEPAGE PITS 1 I Depth Size Numbe�_ _ <br /> SUMPS F I Distance to i rest: <br /> Well <br /> Foun ion 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 ` n <br /> rules and regulations o the San Joaquin County <br /> Home owner or li sa nt'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 on in such nner as to become sub ect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the Ilowing: "I ce fy that in the perfor n of the work for which this permit is issued, I shall employ persons subject to workman's compansa- <br /> tion laws Califor a." <br /> The app cant mu call f 11 re r ns. Co plate drawing o ver ids. <br /> Signed l 0—2,e • <br /> Title: Date: <br /> FOR EPARTMENT USE ONLY r <br /> Application Accepted b <br /> Y <br /> _._..�.�� -= __ t Area <br /> Dae L q� a2 <br /> Pit or Grout Inspection b Date incl Inspection b <br /> x - P Y 14 Data <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 CK RECEIVED BY <br /> INFO CASH DATE PERMIT'N0. <br />• EH 1324{REV.tiS! WKM <br /> EHi .2e 2.5-3 <br /> -3 3 4 <br />