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SAN JOAQUIN COUNTY'PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> / P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> applicnttion is ion is h»ladebincea�made liance xithuSan county <br /> Joaquinfor <br /> Coa permitOrdinancenNoru5k9and/or <br /> lf362install <br /> and the Rules andherein <br /> Aegtllationedescribed. <br /> of SanThis <br /> PP <br /> Joaquin County.,Publl c Health Services. City � <br /> ((``^�h►►i�' S r Lot Size/Acreage <br /> job Address � 4— <br /> Address r� Phone <br /> Owner's Name� _ <br /> Contractor <br /> D CrAddress �-- ense Note Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [,i. � DESTRUCTION L7 OU Monitoring Well <br /> of Service Well ❑ <br /> .PUMPiNSTALLATION _* .. SYSTEM REPAIR ❑ ' <br /> OTHER El <br /> ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL P1T5lSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E <br /> Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> Specifications ` <br /> pomesticlPrivate ❑ Gravel Pack` C7 Tracy Type of Casing_ Type of Grout \` <br /> l'i Public I:1 Other F n Deita Depth of Grout Seal <br /> I I Irrigation —Approx. Dept I I Eastern Surface Seal Installed by <br /> ",� H P. State Work Done ' <br /> Repair Work Done ,ts Type of Pump <br /> " "fa Sealing Material & Depth ,t <br /> I� Well Destruction ❑ Wolf Diameter- <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTICi WORK; MEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I INailabltic thin 200 teet�led it public sewer is <br /> Installation will serve: Residence r 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. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE F-1No. & Length-of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth f Size Number <br /> SUMPS A' LIDistance to nearest: Well Foundation Property Line <br /> ZI <br /> I DISPOSAL PONDS ❑ <br /> �\� <br /> I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin county ordinances, state laws, nd <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 in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 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 Califor 11 <br /> The a Ii must c for all required ins to . Co ate drawing on r (er side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date 3 <br /> Additional Comments: <br /> Applicant - Return all Copies to: San Joaquin County Public He I Services <br /> Environmental Health Permit Services <br /> 445 N San Joaquin, P Box 409, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT NO. <br /> INFO IQlq �qq ?0� <br /> . EH 13-24 MEV,1/N 5) <br /> I� EH 14.26 <br /> I <br />