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rpt{ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ]3V' ENVIRONMENTAL HEALTH DIVISION <br /> Yi 445 N SAN J2009, , PHONE , CA 95201 20 <br /> P O BOX 2009, STOGgTON, CA 95201 (D <br /> F,,as1:a <br /> ^'HERMIT <br /> 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 coMliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i <br /> Joaquin County Public Health Services. <br /> Job Address Y ' City * Lot Size/Acreage <br /> Owner's Name _ (Address' •�� r Phon <br /> (,, <br /> Contractor 1 Address ` License NIS T Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (l DESTRUCTION ❑ Out of Service.We11 ❑ <br /> PUMP INSTALLATION U SYSTEM_ REPAIR OTHER ❑ Monitoring.Well <br /> ' r <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 /> F) Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> EI Domestic/Private Gl Gravel Pack* a_s❑ Tracy Type of Casing_ Specifications <br /> l I'1 11lic [ Othei + n Delta Depth of Grout Seal Typo of Grout <br /> vi rrigation J/ Approx. Depth Eastern 1 S rface Seal Installed by <br /> Repair Work Done L/ Type of Pump � H.P. 1� 1 State Work Done <br /> Well Destruction O Welt Diameter Sealing Material S Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other I <br /> Number of living units: Number of bedrooms , <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.C1 Method of Disposal ` <br /> Distance to nearest: Well Foundation Property LinukAmAAENT <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED # ❑ 'Distance to nearest: Well Foundation Property Li <br /> SEEPAGE PITS 11 Depth Size Number <br /> T'i"V�•+"r'"I'#L 17t[iLi r;til�'iSi�3� 1 <br /> SUMPS E=t Distance to nearest: Well Foundation Proopsl {�($, — <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 laws, 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 parson i such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fol) sru at in theormance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of Ca i' ia. ' <br /> The appli nt IleaU f ire trona. Complete drawing on) <br /> n IV-4-1 <br /> side. <br /> Signed Title: Date: ! �-- <br /> + . FOR DEPARTMENT USE ONL 6 l <br /> `Y Application Accepted by Date Q Area .2 • d <br /> 1 Pit or Grout Inspection by Date Final Inspection by Date <br /> I <br /> Additional Comments: <br /> ' Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 495 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE YERMIT'NO. � <br /> if o-L7 O-D awl 66 �tZ <br /> • Ei113-2t IRteY. /MaF (l�'� <br /> EH 14.20 L <br /> i <br />