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k j SAN JOAQUIN COUNTY F [BLIC HEALTH SERVICES <br /> ENVIRONMENTAL UEALTH DIVISION <br /> 445 N SAN JOAQUIN, `PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ���r4IN 12C,,- i14e� PERMIT EgPIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> I Application is hereby made Fto 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 1852 and the Rules and Regulations of San <br />' fJoaquin County Public Health Servic1es.� <br /> Job Address �� �d it a- F',, <br /> r-4)Q Piz City Lot Size/Acreage <br /> Owner's Name/ �E Address�63 G s Phone <br /> ISl� �d �b <br /> Contractpr Addres a e of P License No fllone <br /> TIYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well <br /> �I <br /> PUMP. INSTALLATION El SYSTEM REPAIR?EK" OTHER ❑ Monitoring Well (7 <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> II. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i' INTENDED USE ',TYPE-OF WELL. PROBLEM AREA .CONSTRUCTION SPECIFICATIONS <br /> in Industrial 0 Open Bottom O Manteca Dia, of Well Excavation Dia. of Well Casing <br /> XDomestic/Private ❑ Gravel Pack 11 Tracy Type of Casing_ Specifications <br /> I I Public C Other 7 OI e 171 Delta Depth of Grout Seal Type of Grout <br /> I I Ir6gation _.Approx. Depth I L Eastern Surface Seal Installed by rMlil dq <br /> Rlepair Work Done X Type .' Pump . .5"u H.P. State Work Done AUJ21AL ✓ d� {�\Y� <br /> Well Destruction ❑ Well Diameter Sealing Material &" Depth <br /> Depth'; Filler Material & Depth <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sower is <br /> ie available within 200 feet.) l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: ;, Number of bedrooms <br /> Character of soil 410'a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 6' <br /> PKG. TREATMENT PLT.❑ '1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> LEACHING LINE 0 No"& Length of lines Total length/sire <br /> FILTER BED ❑ Distance to nearest: Wall � Foundation Property Line <br /> S,EEPAGF PITS 11 Depth Size Number <br /> I <br /> SU'IMPS Ll distance to nearest: Well Foundation Property Line v <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 /> rulles and regulations of the San Joaquin County <br /> Hcme 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 Calif <br /> Ttieapplic must ca II or all required ' ctia <br /> ,iIj Complete drawing on r e side. <br /> Q <br /> Signed X Title: � Date: G <br /> , <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by Date. 1 Araa <br /> Pit or Grout Inspection 6y 11 Data Final Inspection by JA, Date <br /> Additional Comments: - Gem+' <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services A <br /> "i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> lNFOK <br /> FEE AMOUNT'DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . 124(REV. 5 � 690 <br /> 01 14.26 s/ <br /> j-2h h 7 p,( <br />