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5 4 <br /> SAN JOAQUIN COUNTY'PUBINC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 1 <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 141 City _T Lot Size/Acreage <br /> Owner's Name__J_C)e_ F0 /L�-1— Address ��� — Phone <br /> Contractor 0 Addressg e- , License NoJ��?C)V Phone �! <br />{ <br /> TYPE Ot'WELL/PUI NEW WELL ❑ WELL REPLACEMENT P " DESTRUCTION 5-Out of Service Well ❑ <br /> ' \Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM'REPAIR-X -" OTHER❑% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE F" <br /> - .—FOUNDATION AGRICULTURE WELL_ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia_ of Wall Casing <br /> *.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public CI Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I Eastern Surface Seal Installed by O —i� <br /> Repair Work Done �] Type of Pump 0 H•P• — State Work Done <br /> Well Destruction ❑ Wel! Diameter <br /> Sealing Material & Depth <br /> i Depth Filler Material & Depth <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other } <br /> Number of living units: Number of bedrooms s ` 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No.�Compartments <br /> PKG. TREATMENT PLT. ❑ Method of"Disposal <br /> Distance 10 nearest: Well Foundation Property Line <br /> i <br /> 5 <br /> } <br /> LEACHING LINE 11 No. & Length of lines Total length/sire <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Depth Sus '"Number <br /> SUMPS Cl 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 lawi, 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, 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, l shall employ persons subject to workman's compensa- <br /> tion laws m <br /> Th plicant must all for all required in ions. Cor;P0(drawing on r e side. <br /> �� <br /> Signed X Title: _ Date: <br /> f <br /> EPARTMENT USE ONLY �- <br /> ApplicZionAccepied by � * Date Area �1 -- <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 O Box 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE A OUNT REMITTED K It J RECEIVED BY GATE PERMI7"N0. <br /> INFO <br /> EN 114-20I <br />