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Ah �UAWUiN --OUNTY PUBLIC HEALTH SERVTSES <br /> ,ENVIRONMENTAL HEALTH DIVISION <br /> -145: N SAN J OAQUIN, PHONE "'209),468-849 <br /> a- <br /> P O BOX 2009, STOCKTON, CA 95201r, -- <br /> tJ fl <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f — --- <br /> (Complete in Triplicate)! ` <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein describe . s <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 Address6 � `' City Lot Size/Acreage <br /> Owner's Name —Yom W1;A Address � Phone <br /> �� <br /> � n <br /> Contractor Address 20Z f� �,, ���;Ricense No.�����'ri ` Phone . <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> ❑ Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation A ,D' n+"f,+Well Casing <br /> f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing <br /> 11 Public FI Other 1-1 Delta Depth of Grout Seal > / jyout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by S jJb <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth Nll�`rr.t_fA/T� <br /> Depth Filler Material 6 Depth z7pTq� `�R <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR`/ADDITION X DESTRUCTION I I INo septic systempe il,public sewer is <br /> available within 200 feet.) <br /> ��VV <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: _L_ Number of bedrooms,_ <br /> Character of soil to'a depth of 3 feet: Water table depth �+ <br /> SEPTIC TANK ❑ Type/Mfg 4 "si-n��'�r �L- Capacity No. Compartments1 <br /> PKG. TREATMENT PLT. ❑ - r Method of Disposal <br /> Distance to nearest: Well;S�t r Foundation 2/0 Property Line <br /> LEACHING LINE No. & Length of lines _77�� To�tal—length/size <br /> FILTER BED ❑ Distance to nearest: Well-J? — Foundation _ Property Line 0 <br /> SEEPAGE PITS 11 Depth /Size_ r / C ZO 7 Number <br /> SUMPS Distance to nearest: Well,,�� Foundation Property Line 41,422 <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 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 must call for ll required inspections. Complete drawing on reverse side. <br /> Signed X Data: <br /> r <br /> FOR DEPARTMENT USE ONLY fc?Application Accepted by (� — Date Z 0 Area <br /> Pit or Grout Inspection by Date Final Inspection by, Date <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 CKSR CEIVED BY DATE PERMIT'N0. <br /> EM 13-24 IREV. <br /> EH 1 <br /> 4•2e <br />