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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <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 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 /> 1 f! City Lot Size/Acreage <br /> Job Address 1 J <br /> ddress Phone <br /> L-71— <br /> sen is Name % <br /> v ss ease No.4Phone <br /> onti ctar <br /> TYPE OF WELL/PUMP: NEW WELL CD WELL REPLACEME T P DESTRUCTION ❑ Out Monitoring well <br /> of <br /> PUMP INSTALLATION �~ SYSTEM REPAIR ❑ OTHER ❑ <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 /> M Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private Ll Gravel Pack ❑ Tracy Type of Casing_. Specifications <br /> i'1 Public 1-1 Other n Delta Depth of Grout Seal Grout <br /> I I Irrigation _.Approx. DAh ,,tern 1 Surface Seal Installed by <br /> Repair Work Done ❑ Type of PumH.P. State WorfDone444__E_ � <br /> {� <br /> Well Destruction ❑ Well DiameteP Sealing Material & Depth <br /> Depth / Filler Material & Depth r t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INoseptic sin system ermiitted it public sewer is <br /> installation will serve: Residence_... Commercial_ Other available <br /> Number of living units: Number of bedrooms (� <br /> Character of soil to a depth of 3 fest: Water cable depth <br /> . Capacity Na. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. Ll Method of Disposal (� <br /> Distance to nearest: Well Foundation Property Line \, <br /> F <br /> LEACHING LINE ❑ No. & Length of lines Total length/size O <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> .1 hereby certify that 1 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 candies 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 /> 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 forma." <br /> The applit ust call for red ins ctions. Complete drawing on re r e side. <br /> Signe Title: Date: Z <br /> FO DEPARTMENT USE ONLY n <br /> Application Accepted by Date rr,-2-- Area a� <br /> Pit or Grout Inspection by Date Final Inspection by Date�� <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 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKS CASH RECEIVED Y ATE PERMIT NO. <br /> INFO <br /> . EH 13.24 IREV.r/n W <br /> EH 74.2E fie— R2 <br />