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,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 `�2�_! �• � �� City s"rKLy-__-- Lot Size/Acreage <br /> 541AOwner's Name 1A ZJ, ORLftNPO Address Phone <br /> Contractor Address License No. Phone <br /> \TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well fm <br /> * PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 Monitoring Well C7 <br /> DISTANCE TO-NEAREST: SEP_TIC.TANK SEWER LINES DISPOSAL AD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> # INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> 0 Industrial ❑ Open Bottom 0 Manteca Die. of Well Excavation pia. of Well Casing <br /> Ca Domestic/Private 0 Gravel Pack7 1 Ll Tracy Type of Casing_ Specifications r <br /> I'1 Public 1-1 Other Fl Delta Depth of Grout Seal' Type of Grout �- <br /> Irrigation _.-.Approx. Depth" € I Eastern Surface Seul ini-talled by —i <br /> r� <br /> Repair Work pone U Type of Pump r H.P. State Work Done <br /> Well Destruction 0 f Well DiameterSealing Material & Depth <br /> t <br /> Depth Filler Material & Depth w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No 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 /> Characier 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 /> ".,4.---- Distance to nearest: Well Foundation Property,ine <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS 11 Depth Size r Number <br /> SUMPS Ll Distance to nearest: Well Foundation Pro <br /> party Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that i have prepared this applicat' and that e w rk will be done in accordance with San Joaquin county ordinances, state laws,and ` <br /> rules and regulations San Joaquin Co y - <br /> Home owner or lic sed ag nfa signature ties t a toll ing: 'I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any para in such nner as to o e su is t o wo man's compensation taws of California." Contracio►'s hiring or sub-contracting signature <br /> certifies the Poll : "I rtify that in t orma th k for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C Ili rni ." <br /> The applican ust c f r I e uir spectio a 1 to drawing on reverse side. .,. <br /> Signed Title: Date: <br /> FV DEPARTMENT USE ONLY <br /> Application Accepted by Date- Z— Area <br /> .P"r OMatinepection by Date y Z//- 4-Z Final Inspection by Date <br /> Additional Comments: a �i•9 asp, . <br /> Applicant - Return all copies to: San Joaquin County'Public Health Seg i es Ju +i/�.e� h.. a,.' G-i t` / <br /> Environmental Health Permit/Services f-I „/,I AAA A110— <br /> pli¢Cdy.a.rr7� <br /> t 445 N San Joaquin, P O box 2009, Stkn, CA 95201FE '�"" f <br /> LE <br /> O AMOUNT DUE AMOUNT REMITTED CASHD BY DATE�y PEERMIT'NO. <br /> FH 14,2 tREV.txSr e © c �=C n1'1%L. IO � 0 �� <br /> EM 11.2f1 r/ T/V <br />