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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES q <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 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 City. Lot Size/Acreage <br /> � � r <br /> Owner's Name '� <br /> .`0 Address `-' Phone PJB` <br /> Contractor`- y " Address/ F. Z" g License No. + Phone- r <br /> TYPE OF WELL/PUMP: NEW WELL 11WELL R LACEMENT ❑ DESTRUCTION Out of Service Well L1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L) industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public fa Other n Delta Depth of Grout Seat Type of Grout <br /> I I Ifrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ______f H.P. State Work Done, <br /> WII Destruction Well Diameter Sealing Material-A-Depth... <br /> peptha *�' Filler Material & Depth s <br /> TYPE OF SEPTIC WORK: NEWINSTALLATIONI I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is V a <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 ieet:' - -- Water table depth .� 1 <br /> SEPTIC TANK., 0 Type/Mfg Capacitya No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal l S <br /> .i Distance to nearest: Well _ Foundation Property.Line. <br /> r t <br /> LEACHING LINE •Cl; No.-8 Length-of lines ^^' M1"T` "' Total-length/size- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ F <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin c6unty 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 cartify 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 mustf call f all requ 9d ins ctions. Complete drawing on�e arse•side. , C <br /> Signed <br /> Title: 7t % Date: OW — f <br /> R DE -ONLY <br /> Application Accepted by - Date s409s 7 # A a <br /> Pit or Grout Inspection by Date Final Inspection by _ 08taiyC �. <br /> wAdditional 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 I CK I RECEIVED BY DATE PERM17'NO. <br /> INFO /CLASH <br /> EH 13-24IAEV.I/As) <br /> EH 14.20 <br /> l <br />