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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN'J,OAQUIN, 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 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 <br /> �• 14 rf% City 54 Lot Size/Acreage _(O A r� <br /> Owner's Name <br /> Address AlC 6r" , Fes` Phone <br /> Contractor t+�d . Address 1 OltC-4° License No.A5-74 Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C} DESTRUCTION ❑ Out of Service Well ❑ <br /> . -PUMP INSTALLATION-El SYSTEM.REPAIR,❑ OTHERY❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. •"`PROP. LINE <br /> FOUNDATION AGRICULTURE•WELL' OTHER WELL:,,, PITS/SUMPS <br /> INTENDEO,USEw==•r <br /> ;2-TYPE-OF WELL PROBmLEM AREACON57RUCTION SPECiFICAYIONS""' <br /> n Industrial ❑ Open Bottom ❑ Manteca ' Dia of Well Excavation Dia. of Well Casing <br /> C:1 Domestic/Private ❑ Gravel Pack } ❑ Tracy _ f,Type of Casing_ +` _ Specifications <br /> I'i Public 0 Other I-1 Delta Depth-cif Grout Seal n- Type of Grout <br /> 11 Irrigation _.Approx. Depth I I Eastern Surface Sed( Installed by <br /> Repair Work Done L] Type of Pump' H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter f Sealing Material ii Depth <br /> Depth Piller Material A Depth 11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 14—"REPAIR/ADDITION l I DESTRUCTION I I INo septic syslem permitted it public sewer is <br /> ¢ available within 200 feet.I <br /> Installation will serve: Residence" Commercial— Other r <br /> Number of living units: _J_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> t -r <br /> SEPTIC TANK 0§0' Type/Mfg C�t7'f e r_ Capacity &00-.-- No. Compartments <br /> PKG. TREATMENT PLT. GlVis" y .� - F`` Method of Disposal <br /> t <br /> Distance to nearest: :..Well�0 Foundatiom .�t7 Property tine <br /> r <br /> LEACHING LINE No. & Length of lines 3 G a Total length/size o <br /> FILTER BED ❑ Distance to nearest: Well Foundation. Property Line 410 C <br /> i SEEPAGE PITS Depth Q� Size Number <br /> l SUMPS I Distance to nearest: Well _ oundation��__ Property line 2(5� C)l <br /> DISPOSAL PONDS ❑ C21 � 1 08� 12,' <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 rof the San Joaquin County- , I r;,? <br /> Home owner or licensed agent's signature certifies the following)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 workmseg compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,:l shall employ persons subject to workman's compensa- <br /> tion laws of California.. <br /> The apptiean st call far all r ed iFspill4tions. C plat rawing_on reverse side. <br /> Signed ills: -Y A9 of 1^G s� ��O r" Date: /0- <1 / '7 <br /> I DEPARTMENT USE ONLY <br /> Application Accepted by a.,Aaa L Date �3 L Area 0 7-- <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 Servicesl_ <br /> lel <br /> Environmental Health Permit/Service" : ) i <br /> 445 N San Joaquin, P O Box 2009, .Stkn, CA95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED t CK f RECEIVED BY DATE PERMIT'NO, V_AA <br /> INFO CASH <br /> a EH 171.26 3.21(REV.t)xsf <br /> EH 't t�� to _0ld—0-1 <br /> _ <br /> f <br />