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it I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL'HEALTH DIVISION <br /> 445 N SAN JOAQUIN,. PHONE (209)468-3420 <br /> o P O BOX 2009, STOCKTON, CA 95201 WW�ICKW_ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Nv /Zt(Complete i:n Triplicate) �"g. h A� <br /> Appli is hereby made to San Joaquin County for a permit, to construct and/or install the vork he in described. s <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> �fJoaquin County Public Health Services. <br /> <�l,/,�'/ <br /> `rilob Address �r 1Z — ' '"�0x CityC�7� Lot Size/Acreage <br /> Owner's Name 'T "-� `-� Address J Phone 464-266 1 <br /> Gia t'C I!T LCQ License No.FO <br /> ontractor 1 �Address Phone y <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEL ITS MPS <br /> _INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC tFI <br /> f7 Industrial D Open Bottom D Manteca Dia._of Well Excavation Die. of Well C6sng <br /> r I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_+ Specifications -- ` <br /> VI Public 1-1 Other n Delta, Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ' Ll Type of Pump H.P. State Work Done_ <br /> Well Destruction D Well Diameter Sealing Material A Depth <br /> Depth Piller Material i Depth <br /> TyPI OF 'aEPTiC VyORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIONA1 INo 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 soil to a depth of 3 feet: ! 4 Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundati P I <br /> LEACHING LINE D No. 6 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well F ' n PrMVI 9r�e Mai__ <br /> E AL HFAI 1H <br /> SEEPAGE PITS 11 Depth Size Number PERM 1ti5 .RVl"f� <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <br /> 1 hereby certify that h have prepared this'application and that the work will be done in accordance with San Joaquin county%inences. state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licahsad agent's signature certifies the following: "I certify that in the performance ofthe work for whbLit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contract �+h* -contracting signature <br /> certifies the following: "I Certify that in the performance of the work for which this permit is issued, I shall emplo r liFt jeet tvworkman's compensa- <br /> tion laws of California." <br /> The applicant must call farfill requi inspections. Complete drawing on reverse side. <br /> rd�(' Tit l . . /a/rf� -�,_r - Date: Z- e <br /> f► __"`� a <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by L 91 Date Arsa d <br /> Pit or Grout Inspection by Date Final Inspection by On 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 0 Box 2009, Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> SO. EN 13-2I IREV.v x st �/ <br /> EH 11.Ia I � V <br />