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SAN :17�QUIN COUNTY PUBLIC HEALTH P"'-VICES <br /> ` rNVIRONMENTAL HEALTH DIVISIOu <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCgTON,• "CA 95201 <br />! ! PERMIT EXPIRES 1 YEAR' FROM DATE. ISSUED <br /> Ii (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 Glade 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 /> 0 <br /> _ p <br /> Job Address ? 7 _� 14 City � Lot Size/Acreage <br /> Owner's Name Ar, �S �Address _.., �, _.. � _ Phone <br /> !1 ���Address Q License No �_,f'� Phone <br /> Contractor_,•„� . ,T_. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well: ❑ <br /> PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well: 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />` j- FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> 1 �1INTENDED USE TYPE OF WELL -PROBLEM-AREA, CONSTRUCTION SPECIFICATIONS <br /> i n Industrial ❑ Open Bottom D Manteca Dia.of Well Excavation Dia. of Well Casing <br /> n;Domestic/Private Cl Gravel Pack ❑ Tracy Type of%Casing Specifications <br /> ! 1'1 Public to Other fl Delta Depth of Grout Seal Type of Grout <br /> I I,Irrigation _.Approx. Depth I I Eastern, Surface Seal Installed by <br /> Repair Work Dont'• L3- ,+Type of Pump y H.P. F State Work Done <br /> f i Well Destruction_ ❑• Well j?iametei_. Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION FiEPAlRlADDITION I I bESTRUCTION I I; (No septic system permitted if public sewer is;; <br /> i available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> I Number of living units: _I__._.i Number of bedrooms <br /> Character,of.soil to a depth of 3 feet: o "P Water table depth <br /> SEPI�IC,TANK O Type/Mfg 7 Capacity _ No. Compartments <br /> PKG. TREAfiMENT PLT.Cl Fes~ <br /> Foundationt�7 Method of Disposal <br /> ,tom <br /> Distance to nearest: WellProperty Line 3 <br /> �_ <br /> I <br /> LEACHING LINE f No. 8 Lengi)i t1I lines . ' (� � Total length/size -' <br /> FILTER BED f Cl Distance to clearest: Well Foundation Property Line i <br /> SEEPAGE PITS t I Depth �6 ! Size f b� 1? Numberr <br /> !!'` .SUMPS El Distance to clearest:'; Well Qr� Foundation� Property Line amu,T — <br /> k DISPOSAL PONDS ❑ <br /> hereby certify that i have prepared this applicatiori acid that the work Wil 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'lollowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such mannevas 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-campansa- <br /> tion laws of California." <br /> !. The applicant must call for al quired ' ctio . Complete drawing on reverse side. <br /> L! 519n8d �' Tide: ., <br /> Oate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date — Area <br /> Pit or Grout Inspection by Date Final Inspection by LJ Date V)—I Z, <br /> ! <br /> Additional Comments: <br /> x Applicant - Return all,�copies to: Sad Joaquin County Public Health Services <br /> I' )environmental Health Permit%Services <br /> 445 N San Joaquin, ox 2009, Stkn, CA 95201 <br /> t; <br /> i 1 INE AMOUNT DCBE AMOUNT REMITTED CK" ECEIVFt? 9V U-- E PERMi7rN0. <br /> i <br /> EH 13.21 ftV.1ine) <br /> EH 11.211- <br />