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A, _,L CATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES yyy <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (203)46$--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 i <br /> �I <br /> � n � � ✓. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ie <br /> (Complete in 'Triplicate) <br /> Application is hereby made.to SanrJoaquin County for permit to construct and/or install the work herein described. This �i <br /> application is made in complianceivith San Joaquin County 0}}dinance No. 549 and.1862 and the Rules and Regulations of San ; <br /> Joaquin County Public Health Services. <br /> Joh Address tt' •� City Lot Size/Acreage <br /> �! t <br /> Owner's Name Address 5-C. _-- Phone <br /> Contractor. --Address O` / '4 icense No C� d Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL <br /> REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER'S Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ;a $ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial f... ❑ Open Bottom C1 Manteca Dia. of Well"Excavation Dia. of Welt Casing <br /> -1.Cl Gravel Pack' ❑"Tracy 4 Type of Casing_ 5pecif cations <br /> I`I Public M Other . ❑ Delta """ "Dap ti of'Grout Seal Type of Grout <br /> ►. f f , <br /> 11 Irritation —,.Approx. Depth t I Eastern Surface,Sedl.Installed by <br /> Repair Work Done �" Type of Pumg5� H.P. State Work Dona e-G t o 6" d t./ <br /> IF <br /> Well Destruction ❑ Well Diameter Sealing Mil terial Depth <br /> Filler Material 6 Depth " <br /> Depth "• <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION1 I DESTRUCTION t I (No septic system permitted if public sewer is <br /> Z available within 200 feet.1 <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: 1 Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg j Capacity-:--- No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> Distance to;nearest: Well Foundation Property Line I€ <br /> LEACHING LINE Cl No. & Leneth of lines. Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i9 <br /> SEEPAGE PITS 11 Depth i Size Number <br /> SUMPS LI Distance t6 <br /> -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 folfowing;,_'I certify that in:tha.performance of the work for which this permit is issued, I shall riot <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'permifis issued; I shall employ-persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu or all required ins tions. Complete drawing on rove side. <br /> Signed X f Title: �e !L Date: <br /> DEPARTMENT USE ONLY �7 t <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date Final Inspection by Date 7 ' <br /> Additional Comments: i <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> }i Environmental Health Per it/Services <br /> };t 445 N San Joaquin, P 0 13 x 2009, Stkn, CA 95201 <br /> inFEE OUNT DUE f##� AMOUNT REMITTED C SH RECEIVED BY DATE PERM11'NO, 1 <br /> EN 13-24{REV.1/n sS r r� _ _IV �DO <br /> EM 14,20 i ��1••• I fff FFF �3 k <br />