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i - <br /> 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 AddressrCity Lot Size/Acreage <br /> Owner's Name Address Phone "'/0<113 <br /> Contrattar �} - Address `� License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION D out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> (I -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> Cl Public f-1 Other n Delta Depth of Grout Seal Type of Grout <br /> 01) <br /> I I Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by 6- <br /> Repair Work Done 0 Type of Pump H.F. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 017 REPAIR/ADDITION i I DESTRUCTION i I lNo 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 /> Character of Boit to a depth of 3 teat: Watei table depth i <br /> SEPTIC TANK I9-'Typo/Mfg Capacity No. Compartments Z. <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to.nearest:. Well A�Q . — Foundation 67 % Property Line <br /> LEACHING LINE C�-No. & Length of lines Total length/size $;�B <br /> FILTER BED C] Distance to,nearest: Well C3 Foundation i'�S .1 Property Line r <br /> SEEPAGE PITS 4(�ftapth d Size 4;2 � <br /> r � -/I ;6" Number <br /> SUMPS lily Distance to nearest: Well r Foundation Property Line_t <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." V, <br /> The applicant must call for all re ire" inspections. Complete drawing on reverse side. <br /> Signed X r Title: 42,IQ we'A _ Date: <br /> f F R DEPARTMENT USE ONLY <br /> A' liCp <br /> cetion Accepted by Date `8T ` 2� Area <br /> Pit r Grout inspection by Date Inst Inspection by -� <br /> Date <br /> Additional Comments: s - <br /> I` Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH '' <br /> . EH 13-2�trrEY.,insr -r OJ ` It. m JJCa ��CJ 1 ! __j <br /> — �/ 2 <br /> EM t�•7e <br />