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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 O -BOX 2009, STOCgTON, CA 95201 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />j Complete in Triplicate) <br />C 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. 544 and 1862 and the.,Rules and Regulations of San <br />Joaquin County Public Health Services. <br />Job Address _Z3 aoe City Lot Size/Acreage <br />Owner's Name —,7 Address <br />ry <br />Phone <br />Contractor s»GLS --Address r Y icense No ,1 _Phone <br />TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION Out of service Well <br />PUMP INSTALLATION SYSTEM REPAIR OTHER p Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />F FOUNDATION AGRICULTURE WELL OTHER WELL PI.TSISUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA "' CONSTRUCTION SPECIFICATION <br />n Industrial El Open Bottom Manteca Dia. of Well Excavation_ Dia. of Well Casing <br />El Domestic/Private Cl Gravel Pack M Tracy Type of Casing_ Specifications <br />i <br />I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br />11 Irrigation Approx. Oepth,.,.-t-l-Eastern.,,^ _ y:5urfaee Seal Installed by_ <br />Repair Work Done L] Type of Pump H.P. State Work Done W <br />Well Destruction Well Diameter Sealing Material & Depth <br />Depth Filler Material & Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION TY DESTRUCTION I I lNo septic system permitted if public sewer is .la <br />available within 200-teet.l._ ,-- ,,.,,,,;, <br />Installation will serve: Residence Commercial e Other v l <br />i Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: 4 Water table depth i l <br />SEPTIC TANK Type/Mfg Capacity Nb. Compartments <br />G <br />PKG, TREATMENT PLT. Method of Disposal <br />Distance to nearest: Well S Foundation Property Line <br />LEACHING LINE No. & Length of tines Total length/size X Fr <br />F <br />FILTER BED n Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS 11 Depth Si Number_ <br />SUMPS Distance to nearest: Well A222 Foundation L!50,1 ' Property line .r <br />k DISPOSAL PONDS <br />I hereby certify that I have prepared this application and that the work wilt 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 parson 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 all r ired ins tions. Complete drawing on reverse side. <br />Signed X Title a' '!Date: <br />1 <br />FOR DEPARTMENT USE ONLY x <br />Application Accepted by Date Area <br />Pit or Grout Inspection by <br />1c <br />Date Final Inspection by Date Z <br />r, <br />Additional Comments: <br />p <br />Applicant - Return all copies to: -San Joaquin County.;Public Health Services <br />Enbiropmental Health Permit/Services <br />445•N San -Joaquin, 0 Box 2009;=-Stkn,-CA,95201 <br />FEE-1 AMOUNT DUE <br />t AMOUNT REMITTED CX RECEIVED BY DATE PERMIT"N0. <br />INFO <br />j[ p+ p Ift-.29ffolEN13-24(REV.i H 5J Spq, f I rJS 8 f7 Z 2- <br />EH 14.20 <br />1