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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> + 3 ENVIRONMENTAL HEALTH DIVISION <br /> ►'r 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> -. P O BOX 2009, STOCKTON, CA 95201 <br /> -'PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED <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 coWliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressFiZ4 '�`�" c-)477 .City *< Lot Size/Acreage S <br /> /� 6r� <br /> Owner's Name Address Address` F �!� Phon i <br /> Contractor rCitw+'� _____ __ Address f8a5' YCkSSM � F License N4 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring,well C <br /> - � r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .PROP. LINE <br /> FOUNDATION ,AGRICULTURE WELL OTHER WELL" PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F} Industrial ❑ Open Bottom ' 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> M Domestic/Private Gl Gravel Pack Tracy Type of Casing_ Specifications <br /> I'} e.blic M OtheF n Delta Depth of Grout Seal Type of Grout <br /> I Irrigation _Approx. Depth I Eastern l S rface Seal Installed by <br /> Repair Work Done (Type of Pump H.P. l State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ! I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Linn,AMUENT a <br /> LEACHING LINE ❑ No. & Length of lines Total length/size f�'E <br /> FILTER BED ; 0 'Distance to nearest: Well Foundation Property Lik, <br /> SEEPAGE PITS 11 Depth Size . Number <br /> '� <br /> SUMPS LI Distance to nearest: Well Foundation i Propet�j�f�,$,?`-� Ft�'u`iL{�"' UI'"i:;4°�� <br /> DISPOSAL PONDS ❑ w <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, I shall not <br /> employ any person i such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the 'son <br /> i cert, at in the ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cal' is ' <br /> The appli nt u t calf ire ctions. Complete drawing on v e side. -/ <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONL <br /> Application Accepted by hate Area .21-6 <br /> Pit or Grout Inspection by Date Final Inspection bya.41c-- 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 <br /> INFO A(M�OUNT DUE AMOUNT REMITTED ,SCK RECEIVED BY ¢DATE PERMIT'NO. �L <br /> . EH 13-24 TREY.v h Sl F� ! S 0-0 � O <br /> ` � <br /> EH t�•7e <br /> i <br />