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- A.Nj -EQUIN COUNTYPUBLIC HEAHEATH SERVICES <br /> NVI-RONMENTAL-HEALTH- DIVISION - <br /> 445 <br /> N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I - <br /> i (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 In made in comrliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Service <br /> Job Address �' �l� 1• City Lot Size/Acreage <br /> Owner's Name � � a�jd Address Phone <br /> I � 4 <br /> Contractor ff 1,R-41.AaAddress . nse No. Phone r <br /> TYP"c OF WELL/PUMP: 1 I N WELL WELL REPLACEMENT .. DESTRUCTION Cl Out of Service We11 0 <br /> PUMP INSTALLATI N ~~~V SYS7 REPAIR OTHER^0 Monitoring Well <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J&fkX POSAL FLD. PROP. LINE f <br /> 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _.J <br /> y .•,vINTENDEO USE -TYPE OF WELL _PROBLEM AREA CON9TRUCTION SPECIFIC I(ANS <br /> C1 In trial pen Bottom D Manteca !D a. of Well Excavation' "Dia:of-WeII"CF51ngY'LR`- <br /> Domestic/Private C!1 Gravel Pack 0 Tracy Type of Casihl_ Specifications 4' — <br /> b = �. <br /> ('I Pubfc (.1 Other n Delta Depth olGrout'Seal Ty of Grout <br /> I tion--- --^- Approx, De //l.I Eastern rSdriac`e Sael Installed by � t <br /> Repair Work Done 0 Type of Pump –��"``f H.P. f. State Work Dane <br /> Well Destruction 0 Well Diameter Sealit rias & Depth v •- w r_ f�' <br /> Depth Filler tfiatirial 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR"/A'ODITION 1=1 'DESTRUCTIONTI I (No septic system peimitled-if public se er is <br /> available within 200 feet.) <br /> j Installation writ sewe�Res"�idence` ComMercial Other } �^ <br /> Number of living units: -lumber_of bedrooms <br /> Character of soil to a depth.of'3 feet: 1 Water table depth <br /> SEPTIC TANK. Cl`•Type/Mfg �� Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 i" { f Method of Disposal j <br /> i1DiMance to nearest: Well Foundation ioperty Line <br /> i � 4 <br /> LEACHING LINE O t;No!& tength.of lines__ f Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I. Depth� Size Number _ <br /> SUMPS LI Distance to nearest: Well Foundation Property Line , <br /> DISPOSAL PONDS 0 <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs and regulations of the San Joaquin County <br /> Nome owner or licensed agent's signature certifies the following: "I certi(y that in the performance of the work for which this permit is issued, l shall not <br /> employ any person in such manner as..to come subject to workman's compensation laws of California.',.Contractor:s_hiring or su.blcontracting signature,, <br /> I certifies the following: "I certify that i the pertormance'of the work for which this permit is Issued,1 shall employ persons subject to workman's compense_ <br /> tion laws of California." r <br /> The applica t t all for all re ed in ctions. Complete drawing on re r side, .---� <br /> /� <br /> Signed I Title: Date: .iq <br /> DEPARTMENT USE ONLY ! <br /> j ^•�� L <br /> Application Accepted by Date 1t J Area <br /> r <br /> Pit or G Inspection by Oats Final Inspection by <br /> Additional Comments: <br /> f Q <br /> Applicant - Return all copies to: San Joaquin County Public ealth Services �.JtMJL11V>^•�� ��,� <br /> l Environmental Health Perm t/Services f <br /> fr 445 N San Joaquin O B 2009, Stkn, CA 95201 <br /> FEEINFO AMOUNT DUE AMOU T REM TTEO C H RECEIVED BY AT 0_1'N '. <br />