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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> IP 0 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 A City t,Lot Size/Acreage <br /> Owner's Name Address �� e-C� Phone <br /> `\ AAQA�"��4 <br /> Contrat:tar �i�`�«�gA,�y Address1,� � �'�rO�.C�.' License No,�� ��1 Phone ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> ...PUMP INSTALiLATION 0--- SYSTEM REPAIR' OTHER ❑ Monitoring Well G7 <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 /> CI Industrial Cl Open Bottom 0-Manteca Dia. of Well Excavation Dia. of Well Casing l <br /> XDomestic/Private ❑ Gravel Pack L] Tracy Type of Casing_ Specifications <br /> i'1 Public f-1 Other n,Delta 'Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I I.Eastern urfaee Seal Installed by <br /> Repair Work Done Type of Pump ' H.P. 3 � State Work Done <br /> Well Destruction ❑ Well Diameterl t ti 1 Sealing 14aterir►1 & Depth <br /> Depth �. Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION`l'l DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> ' Installation will serve: Residence Commercial`_ o <br /> ther. <br /> Number of living units: Number of bedroomsr <br /> Character of soil to a depth of 3 feet: t T Water table depth <br /> SEPTIC TANK ❑ Type/Mfg,J '" Capacity No. Compo st, <br /> PKG. TREATMENT PLT. 1:1 '� i ��z Method of od <br /> /"7 r <br /> ..Distance t64 nearest: .__Welk—.Foundation Property Lin@ <br /> fl L <br /> i <br /> LEACHING LINE.' ✓ Ll No. & Length'61 lines r r Total length/size 'f <br /> FILTER..BED ... _ _. ❑ Distance.to nearest:,.�.•_.�Weli. _Foundation" Propeny_.I <br /> SEEPAGE PITS 11 Depth Size Number L rl Iry"" <br /> SUMPS LI Distance to+nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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: 1 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 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 taws of California." 4 ' <br /> The applicant must call for all required inspections. Complete drawin on reverse slide.. <br /> Signed X ' "C TitleDate: <br /> } FOR DEPARTMENT USED LY <br /> Application Accepted by Date Area �L <br /> Pit or Grout Inspection by ` Date Final Inspection by Date 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK III RECEIVED BY DATE PERMIT NO. <br /> INFO CASH �] yy <br /> EH 13.14 1REV.i � U <br /> EH 14-28 i f/1 ? <br />