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SAN aUIN COUNTY PUBLIC HEALTH � 'ICES <br /> ,sNVIRONMENTAL HEALTH DIVISION <br /> 445NSC420 <br /> BOX 2009, STOKTON, CA PO <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 herei bed. is <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an egulatio of Sa <br /> Joaquin County Public Health <br /> Services. 1 <br /> Job Address/ ry" l,L� j1�4110 0 City�d�o in Lot Size/Acr ge Q <br /> Owner's Name 01A P.flak �OKddress c /may R� Phone a y d <br /> Conttactor U !e-Y [ Address �[`af-'T <br /> P�CJ , (")if l License No.O�"l�3 Phone c;11 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 OA P- SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS f% Wall <br /> ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of asin <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing! C�� Specifications <br /> I �blic f:l Ot�1er fl Delta Depth of Grout Seal Type of Grout <br /> Ir'pation 3av Approx. De th / I I Eastern Surface Seal Installed by <br /> JRe it Work Done U Type of Pump alk I),r. H.P. _! (O State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line d <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 laws of California." <br /> The applicant st call for all requir d inspections. Complete drawing on reverse side. <br /> Signed Title: c"_ iLeData: <br /> F MENT USE ONLY I q <br /> Application Accepted by — Y� Date —�� rea Q • <br /> L <br /> Pit or Grout Inspection by Date Final Inspection by Date* o <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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE gPERMIT*NO. <br /> EH 13-24(REV.1/n5) WIL , -0 � �`� • ~� "' <br /> H 11.26 l�J l� �s / <br /> t /� <br />