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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />445 N SAN JOAQUIN, PHONE ( 0 <br />P 0 BOX 2009, STOCKTON, CA16 ! <br />PERMIT EXPIRE I YEAR FROM 11SU <br />(Complete in Tripli _ <br />Application is hereby made.to San Joaquin County for a permit to construct aer tall the rr cribed. is <br />application is made in compliance with San Joaquin County Ordinance No. 54 <br />Joaquin County Public Health Sere cea. p <br />�iC ny�Job Address ��/ L=. r S'i City d�I� G allGet Size/Acreage <br />Owner's Nemo/lob r+sdh'01 e0_0 r fddress _� C�J_0/X __ 30 > C v hone M u <br />10_601_[ 13 ��r ' e .fid 1 3 I 7-S <br />Conttaclor s,�'O'��1^ SSR W—T Addressnse NE). _� Phone <br />11 <br />TYPE OF WELL/PUMP• NEW WELL ❑ WELL REPLACEMFNT 17 DESTRUCTION O Out of Service Well ❑ <br />PUMP INSTALLATION O SYSTEM REPAIR C OTHER ❑ Monitoring Well L} <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />n Industrial <br />f) Domestic iPriti-ate <br />I' i Public <br />I t Itri(lation <br />Repair Work Dont U <br />Well Destruction ❑ <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom <br />❑ Manteca Dia. of Well Excavation <br />❑ Gravel Pack <br />0 Tracy Type of Casing__ <br />fa Other <br />i l Delta Depth of Grout Seal <br />— Approx. Depth <br />I 1 Eastern Surf ce Sedl Installed by <br />.r- <br />Type of Pump s� <br />H.P- ` State Work Done _ <br />Waft Diameter <br />Seali �Material Z Depth <br />Depth <br />Piller Material R Depth G <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />V� <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION i l INo septic system permitted it public sower is <br />available within 200 feet.) <br />Installetion will serve: Residence T Commercial _ Other <br />Number of living unity: Number of bedrooms _ <br />Character of Ball to ■ depth of 3 feet: PAYP cc+5�ger table depth <br />SEPTIC TANK ❑ Type/Mfg Capaciry__REIICI�V ompartments <br />PKG. TREATMENT PLT. Cl n EC <br />1 (� pAe od of Disposal <br />Distance to nearest; Well Foundation U Prdpe °�ty� - a <br />SAIq J0A .l.!I!� C0l,JNJy <br />LEACHING LINE Ll No. & Length of lines U LI��A,jvICES - <br />FILTER BED ❑ Distance to nearest: Well Foundation L[ �Trnrki I A <br />SEEPAGE PETS I I Depth Size Number <br />SUMPS LI 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 taws, 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 i■sued, I shall employ persons subject to wori.man's compensa <br />tion laws of California," <br />The applicant all f requ- d inspections. Complete drawing on reverse side <br />Signed 7C_ Title; � /��� taste: <br />X93 <br />FOR DEPARTMENT USE ONLY <br />Application Accepted byDate /moi "r <br />—Area <br />Pit or Grout inspection by Date Final Inspection by � r✓X�S��_ Date��% t� <br />Addiiionsf Comments; <br />Applicant - Return all copies to: San Joaquin County Publlc Health Services <br />Environmental Health permit/Services oorJC u 7 <br />445 V Sen Joaquinnn�v c�Eox 2009, Stkn, CA 95201 r (� <br />IFFf AMOUNT DUE AN,OUNT REMITTED CASH RECEIVED BY DATE PERMIT NO <br />EH I i -2C+ -x <br />I <br />