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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P <br /> 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. je1L <br /> — 4:ot Size/Acreage <br /> Job Address City MCI. <br /> a Address« J �r/G'�d •� r / �Cr Y� �(. e J` Phone <br /> Owner's Name r Y1 rl J ( r 7 h /V1 C/ +z —1 ­ < <br /> Sp L Address License No. Phone <br /> Contractor rte — <br /> of service Well 0 <br /> TYPE OF WELL L/PUMPMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out Monitoring Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O (} <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 /> n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack O Tracy <br /> Type of Casing._ Specifications <br /> I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation `.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION WtESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence__eCommercial_�j Other j <br /> Number of living units: J— Number of bedrooms L— �' 7 <br /> Character of soil to a depth of 3 feet: ✓� L� 110" Water table depth <br /> SEPTIC TANK We Type/Mfg !.'i &1 C/ it Capacity 6 No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> r r Method <br /> Distance to n rest: Well � Fou <br /> y ndation_V_ Property Line <br /> P�S'r/�Y�- e 'T/4�r le . <br /> LEACHING LINE C1 No. & Length of lines Tgtal length/size <br /> FILTER BED PI Distance topearest: Well Foundation .- Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to 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 following: "I certify that in the performance of the work for which this permit is issued, 1 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 California." <br /> The applicartt�must call for alt r uired inspections. Complete drawing on reverse side. <br /> (/�� �, �{'Ir,CsL Date: 9''w ,Z—V 2— <br /> Signed X >i — Title: <br /> FO EPAR ENT USE ONLY <br /> 00 <br /> Application Accepted Date 's a <br /> Pit or Grout inspection by Date Final Inspection b Date,crc%! 7 �� <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 /> FEEAMOU T DUE AMOUNT REMITTED CASH CEIVED BY D E PERMIT'N0. <br /> INFO <br /> . EH 13.24(REV. iA5) <br /> EH 11.26 fff <br />