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r <br /> SANr)AQUIN COUNTY PUBLIC HEAT TH RVICES <br /> "1 ENVIRONMENTAL HEALTH DIVISIUA <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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 Address 1817 Danks City .�f kn -. Lot Size/Acreage <br /> Owner's Name l ea C y Address 3354 phone 9 8 2-4 5 2 6 <br /> Contractor Uaak G1 zli Address ?024 E. ChazLez. License No.3 7 5 4 Phone 982- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONAUrOut of Service Well ❑ <br /> PUMP INSTALLATION E) SYSTEM REPAIR ❑ OTHER C1 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial 0 Open Bottom ❑ Manteca is. of Well Excavation _� Dia. of Well Casing <br /> C1 Domestic/Private 0 Gravel Pack7 0 Tracy Type of Casing_ Specifications <br /> V1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation _Approx. Depth I I Eastern Surface Seal installed by \ <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter 6" Sealing Material A Depth794416 40iio. 76, 9 6 a ck <br /> Depth 1 1 5 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRrADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet,I <br /> Installation will serve: Residence— Commercial Other— N <br /> Number of living units: Number of e EXPI-h--" ED <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.: 0 Type/Mfg �r1txdGttyt� No. Compartments <br /> PKG. TREATMENT PLT. 0 a i,,} r199�1 GG 1.6 + Method of Disposal <br /> Distance to nearesw(��" 4 G�lmP[Q GdiGr Ins ecte(roperty Line <br /> ­=,'1,81Kealth Divi& A , R <br /> LEACHING LINE ❑ No. & Length of line _i j t Total length/size <br /> FILTER 8ED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number , <br /> SUMPS LI Distance to nearest: Well Foundation Property Line - <br /> DISPOSAL PONDS 0 <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 /> Horne owner or licensed agent's signature candies 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 certif 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 applican s a r re ns i s. Complete drawing on reverse side. <br /> Signed Title: V2 Cf-a.4-4 /),2D0 _-- Date: 3 92 <br /> FOR DEPARTMENT USE ONLY �3 <br /> Application Accepted by Date Area <br /> s Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> r <br /> } <br /> FEE AMOUNT DUE AMOUNT REMITTED PECEIVED BY ATE PERMIT'NO. <br /> FO <br /> a EH 13-24 tREV.It M 5) <br /> EH 14.26 <br />