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� K <br /> SAN -JOAQUIN COUNTY PUBLIC HEALTH -SERVICES <br /> b / ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> YCOX <br /> P O BOX 2009, STOCSTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Q (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 a.ad Regulations of San <br /> Joaquin County Public Health Services. <br /> iJob Address City Lot Size/Acreage <br /> A.�.�.__. _, _ ..� r Phone <br /> #Owner's Name Addrels <br /> Y( N i3 .r..1,L: 1.^z, <br /> Contracto �n Address a No. Phone <br /> l TYPE OF WELLIPUMP: NEWELL - / WELL REPLACEMENT ❑ yDESTRUC EON Out of Service Well ❑ <br /> PUMP INSTAL ION SYSTEM REPAIR 0 OT ER p Monitoring Well <br /> I 1DISTANCE TO NEAREST: SEPTIC TANK -., EWER LINES DISPOSAL FLD. 0 f r <br />' FOUNDATION Fs $AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYP .OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC 1 S ' <br /> 1n Industrial pen Bottom ❑ Manteca Dia. of Well Excav Dia, of Well Casing <br /> j J1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> FI Public f 1 Other n Delta Depth of Grout Seal Ty a of Grout <br /> j ngation —Approx. De th LI Eastern Surface'Seul Installed by <br /> # ' State W Dr! — <br /> Repalr Work Done t7 ,Iype of Pump H.P. <br /> Well Destruction 2/Well Diameter Sealing tdaterisl-6_D,epth r <br /> Depth Filler Material i Depth <br /> 1 `TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION 11 (No septic system permitted it public sewer is <br /> f j y available within 200 feel,I <br /> ` Installation will"serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> a t Character of soil to a depth of 3 feet: ^ Water table depth <br /> " s No Com rtments <br /> SEPTIC TANK. ❑ Type/Mfg Capacity � <br /> `--',PKG:- REATMENT PLT. L1 Method of Disposal <br /> ' Distance to nearest: Well Foundation Property Line <br /> ! CLEACHING LINE ❑ No. & Length of lies Total length/size <br /> :FILTER BED\ n Distance to nearest: ' lWelt Foundation Property Line ( <br /> � fie.' <br /> FSEEPAGE PITS 11 Depth Size Number <br /> jSUMPS Ll Distance to nearest: Well Foundation Property Line ' <br /> ,DISPOSAL PONDS\ ❑ <br /> a <br /> I hereby certify that IAhave 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 /> nature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licsnsefd agent's sig <br /> 'employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "t certjfy that in the rt rmance of the work for which t permit is issued, I shall employ persons subject to workman's compensa- <br /> lion laws of Cath <br /> The applica t-m call-for-aw►! iredl Ctions� 'omplpile-drawing oo- ve -side -+ <br /> }Signed itle: _ Date' <br /> 2�� _72= <br /> FO DEPARTMENT USE ONLY r ' <br /> f <br /> tApplication Accepted by _ Date qA f1 fes'` -- Area <br /> i!�ti '?1 Z- _— <br /> � 'Pif-or, TG[ijiit Inspection by Data � Final Inspection by / D <br /> Additional Comments: I.`•.�� �> A6&,A <br /> Applicant -.Return all copies to.',. 'San-Joaquin County Public Health Services' <br /> Environmental Health Permit/Services <br /> I r ' ,45,N, San',J}oaquin, P 0 Box 2009, Stkn, CA 95201 <br /> ¢ <br /> --A�-, CK <br /> fEE',. - AMQUNT 1]UE AMpENT R IT-TED <br /> CASHBY 0 E ISN <br /> t) r CASH - <br /> IN <br /> r _ <br /> a .'EH 13'24 IREX14 IA-26 <br /> V.-h/X 51 lt- fa•• - �. -�r <br /> ` f "r j <br />