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SAN JOAQUIN COUATTY PUBLIC HEALTH SERVICES <br /> u <br /> ENVIRONMEZ47AL HEALTH DIVISION 4 <br /> 445 N SAN JOAC:i T_N, PHONE (209)468-3420 <br /> !' <br /> P O BOX 206"' 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 /> ,/� <br /> ✓ �J rCI'� <br /> Joh Address <br /> City Lot Size/Acreage <br /> r <br /> 140-1 <br /> Owner's Name N Address Phone <br /> r <br /> Contracto I� i Address ig License NoS75T, Phone ♦_) <br /> TYPE OF WELL/PUMP: NEqV WELL IDWELL REPLACEMENT 11 DESTRUCTION t of-Service Well ❑ <br /> Ip PUMP INSTALLATION D SYSTEM REPAIR L7 OTHER Q Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE <br /> .1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial I` ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> {_l Domestic/Private 1 ® Gravel Pack ❑ Tracy Type of Casing._ Specifications <br /> I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation , .-•_..Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Dons .L] Type of Pump H.P. St ��� <br /> Sealing Material — <br /> Well Destruction '© Well Diameter Depth <br /> Filler Material b Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I i iNo septic system permitted if public sewer is <br /> available within 200 feet.) l` M <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 I ❑ Tyo'/Mfg Capacity = No. Compartments <br /> PKG.TREATMENT PLT.Ll >;`' „� w Method of Disposal <br /> Lx i' Distance-to-nearest: TLWell'.. Foundation_. - Line <br /> i <br /> LEACHING LINE ❑ No. & Lengths of-lines ATotal length/size <br /> FILTER BED 11111113 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS' -R-,— ^l I Depth %—`° Size Number <br /> U ` <br /> ;SMPS J=-^t� i_oLI Distance to nearesii Well Foundation Property Line <br /> -iSPOS. PONDS ❑ <br /> i hereby certify than 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 regulatidns of the San Joaquin County w <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 i <br /> employ any person in such manner as to become subject ta"workman's compensation laws of California.•' Contractor's hiring or subcontracting signature <br /> cartifies'the following: "I certify that in the performince:df the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion 136 of-Catifornlar'- ) <br /> The applicant.m� t,'call+foi all req 'r i spections. Complete drawing on reverse side. <br /> Signed X - Title: ^�,I a0N - _ Date: r' 'L <br /> f FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Are <br /> Pit or Grout Inspection by Dater Final Ipaction by to <br /> Additional Comme Its: <br /> Applicant -( Return all copies to: San Joaquin_C unty Public Health Services <br /> Environmental;Health Permit/Services <br /> 445 N San JamiiiLde, P 0 Box 2009, Stkn, CA 95201 <br /> FEE) AMOUNT DUE AMOUNT REMITTED. CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH43.24 tREY.1/85) <br /> WID <br /> 6 <br /> ov <br /> EH 74-Ie t <br /> I. - l <br />