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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> i P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> P �- <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaq�An County for a permit to construct and/or install the vork herein described. This <br /> appliestion is made in compliance vith'San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County/Public Healt ti. <br /> l/ ,!�(,, ,'/ervice ��, y <br /> Job Address !F City —F==— Lot Size/Acreage <br /> Owner's Nam <br /> -yo I 4 Address Phone <br /> Contractor! Address c e License No. td Phon <br /> TYPE OF WELL/PUMP: ;I�I NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUM j INSTALLATION E) SYSTEM REPAIR OTHER 0 Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE O <br /> FOUNDATION 'AGRICULTURE WELL` OTHER WELL PITS/SUMPS Q <br /> INTENDED USE Ty' OF WELL j PROBLEM AREA, CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial D Open Botiom ' .D Manteca - Dia. of Well Eiicavation Dia. of Well Casing <br /> ll <br />�. �DomesticlPrivate Cl Grav'el Pack L] Tracy Type of Casing_ Specifications <br /> 1'1 Public C1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done " F <br /> Wait Destruction 0 Well Diameter � Sealing Material A Depth <br /> Depihi� r ' Filler Material A Depth . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADD17ION I 1 DESTRUCTION I I,INo septic system permitted it public sewer is <br /> = available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other O <br /> I <br /> Number of living units: I� Number of bedrooms <br /> Character of soil to a depth ofi3 feet: ' Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg v Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ I _.,- Method of Disposal <br /> Distance to nearest: Well ' Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well i `Foundation Property Line <br /> SEEPAGE PITS { I Depth Size Number <br /> SEEPAGE PITS <br /> I ! <br /> SUMPS U Distance to nearest: Well Foundation- Property Line <br /> L DISPOSAL PONDS ❑ iIr <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:isignature 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 in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or,subcontracting signature <br /> I certifies the fallowing: "I certify t�at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." <br /> Thea ant st call for all requ inspe. ns. Complete drawing on r rse side. <br /> I <br /> Signed Title: [) ---- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by k&� _- Date L �' `Area <br /> Pit or Grout Inspection by II Date Final Inspection by Date <br /> d <br /> Additional Comments: II <br /> i�. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.- <br /> INFO L <br /> �j �1, © <br /> . EH i13,24 TREY.I/n SI ' Z <br /> EH t4Se <br /> I �. <br />