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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-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. I <br /> i r O79 /Acreage <br /> rii5t=Address po Q City <br /> a <br /> Owner's Name ddre �r ' <br /> --- � rte- r �r e@eNo.1 3_32-Ph one <br /> ContMEtor� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION L1 Out oP Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 4 SEWER LINES 0 DISPOSAL FLD. d PROP. LINEo2-QP_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL—9200-- PITS/SUMPS <br /> "INTENDED USE 4-T-YPE OF WELL PROBLEM AREA xCONSTRUCTION SPECIFICATIONS 6 u <br /> I <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing �'Z'�r~ �- Specifications f. <br /> i W <br /> I'] Public Other fl Delta Depth of Grout Seal Type of GroutMMaV _ <br /> I I Irrigation z�� ?�QApprox. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done LJ `Type of Pump H:P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence....^ Commercial — Other C <br /> Number of living units: Number of bedrooms <br /> Character 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 /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t� <br /> SEEPAGE PITS 11 Depth Size Number v <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line _ <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 s call forr quired inspections, Complete drawing on reverse side. �d <br /> , n ',� �- T <br /> rlr5'rg en d Y - _.L�(/� ✓-.� ...--�.. �TitleDate o <br /> FOR D4MRTMENT USE ONLY <br /> Application Accepted by Date . f�-f -moi -, Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> It IT 11 4P <br /> Additional Comments: &IaLeCrda. ✓�� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 1-41-4 • AW <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> I <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br />{ . EH111t-2E4-20IREV.Iin51 , t�U <br /> EH F9 17 &? Cr <br />