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f � <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 /> 'F <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby wade 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 = ` *� <br /> 6LI` -- City.fta O&UP Lot Size/Acreage C�4- 5 <br /> Owner's Name 67- Address V -fly Phone S <br /> Contractor 1LdSAtl1` 2- _Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7.1 DESTRUCTION Cl Out of Service Well ❑ <br /> k PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER M Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom 0-Manteca t� Dia. of Well Excavation Dia. of Well Casing <br /> I'l Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing_ Specifications <br /> Il Public p CI Other n Delfa` F Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern ; Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump 1W,P. - State Work Done _ <br /> Well Destruction ❑ Well Diameter 66s:11ng Material b Depth <br /> Depth, Filler Material 3 Depth L <br /> i, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION' DESTRUCTION I I iNo septic system permitted it public sewer is <br /> q. [{ available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other) - <br />` Number of livind:.units; I Number'of bedrooms <br /> ' <br /> GharaCer of et)to a de�pth`01,3 fe�a't: f depth <br /> SEPTIC <br /> TANK,� 4 �1;{iTrp`e/Mfg L& G Capacity 1-00 No. Compartments <br /> PKG. TREATMENT PLT. ❑ / / Method of Disposal <br /> Distance to nearest:. ...._Well �Q�.,- unclation-- ------- Property Line /,0 / <br /> LEACHING LINE ❑ No. & Length of lines Total;length/size <br /> FILTER BED [-IDistance to nearest: Pro Well Foundation perry Line <br /> I <br /> yy <br /> SEEPAGE PITS 11 Depth _ _size .� Nursfber <br /> SUMPS ! LI Distance to nearest: Well`,. Foun dationf { Property Line <br /> qq � rr <br /> DISPOSAL,.PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be do'4'in accordance with San Joaquin county ordinances, state laws, and <br /> e a Y <br /> rules and regulations of the San Joaquin Count, I <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 Erring 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." <br /> The applicant mus ccqll for all re uirp inspections. Complete drawing on reverse side. ' <br /> Signed X C Title: I - Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application',Adcepted by <br /> Date ea r2/S <br /> Pit or Gram Inspection by Date Final Inspection by Data�� <br /> Additional Comments: ^ <br /> Appli�ant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services i <br /> p 445 N San Joaquin, P O Box 2009, Stkn, fCA 95201 t <br /> I FEE-._,. CK_ W - ---DATE-- <br /> -NFO AMOCiNT'DIJE-`^" AMOt7NT REMITTED CASH "RECEIVED BY OGTE �PERMtT`tVO�" <br /> c <br /> . EN 43•S4 inEV.i i x Si 1 �F <br /> v k <br /> EN 14Ie C0o <br />