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r <br /> SAN JOAQUIN COUNTY PUIILIC HEALTH SERVICfiS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEQ <br /> (Complete in Triplicate) <br /> APPlieRtloo Is hereof souls.W Bap Joaquin County for a perslt to construct end/or Install the wort herein described. This <br /> aypllcatlop Is srde in cotyllance with Soup Joagc:n County Ordinance No. 549 and 1862 arta the Rules and Resuletlom of sent <br /> Joaquin County Public Health 9er.ices. <br /> ,r <br /> Job Address A!!!"J 9 ✓ � '��� y ry� CnY �O wt Sl tt/Atrca6e c <br /> Owner's Namer 611/f!✓a��i ��iE Address/�[—/� � Q�/�� v PMns S t <br /> Cont'-sior�. Address f't'�F License No. 7 PhoneAl <br /> TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT (T DESTRUCTION Ll Out or S.rwICa wall '_1PUMP INSTALLATION [D SYSTEM REPAIR C OTHER ❑ stonitorLg Yell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL LD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L)Indlmm� ❑Open Bonom ❑ Manteca Dia.of Wan EsavaUon Oen.of Well Camp <br /> mani, <br /> CI Do /Priwne ❑ Gravel Pack ❑Tracy Type of Casino_ Specdicatans <br /> I1 Public ❑Other fT Delta Depth of Grout Seal Typo of Grout <br /> I I W,wk i _Appro,. Depth I I Eaatarn Surface Saul IneulNd 0,_.. <br /> Repair Work Done ❑ Type of Pump H.P. Stet.Work Done_ v <br /> well Destruction ❑ Well Diameter Seallos wtr.lal A Depth - <br /> Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAMIAODITIONA DESTRUCTION I I (No P,.c syuem p@,H ilt o d pudic sewn u <br /> a,jiaDl,within 700 fest.) <br /> Installation will un.: Residence_ Commercal_ Other <br /> Number of living units_L Number of bedrpms <br /> Charactw of sole to a depth of]Mt: Water table depth <br /> SEPTIC TANK ❑ Type/Mag Goaciry zorv�l+.�,-No. Comparthionn <br /> PKG. TREATMENT PLL❑ Method of Disposal <br /> Dintnco to neweeP Well Foundation Property Lina <br /> LEACHING'.INE ,J( No.d Length of lines _/_ O r Tofat length/sits <br /> FILTER BED ❑ Disronce morsel:tomorsel: Well n FoundationProperty aim E <br /> SEEPAGE PITS I I Doth Sire Nutria, <br /> SUMPS LI Motorcar to maresn Well Foundation Property Lim <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify tnal I how prepared this appacelan and that the work will be done in accordance win San Joaquin county ordinances, state lows, and <br /> rule$and rpulatiom of the Son Joaouin County y <br /> Homs owmr or licenW agent'$Wriotura certifies IN following: "I certify that in the performance of the work lot which this pemvf is issued,I Nall mt i <br /> employ any Semon wf such nlanmr as to baccem wbteCt to workman'$compensation awe of California."Contractors hiring or wb­conlracting signature <br /> con:fwa tM foYowbp:"I Can't,that in this qA 'rharwo of the work for which this permit is issued,I atoll employ persona subtect to wwkrmn's compenss. <br /> tion lows of Calitoma:' <br /> TM wan t up for YI rpuir i Oections. Complete drawing on reverse side. <br /> Sig r Tins: n��� Dne:'7��% <br /> F R DEPEP T ONLY <br /> ApplKatbn Accepted by Data v Ar <br /> Pit w Grout Inspection by Date Fiml Inspection by Das <br /> Addhbml C.,ranta: <br /> Applicant - Return all copies to: Tan Joaquin County Public Health SerVio.. <br /> snYirpomental Health Permit/Services 'Y <br /> 445 H Sae Joaquin, P O Box 2009, 3tkn, CA 95201 01 <br /> 5Q IHFQ AMOUNT DUE AMOVNi PfMI FO CASH RECEIVED eV DATE PERMIT NO j <br /> . Fw stir lalV.treat � w a,� �� <br /> In tai <br />