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3 �Sd <br /> SAN '.QUIN COUNTY PUBLIC HE � T <br /> iMVIRONMENTAL HEALTH DIV S / <br /> .�/ 6 <br /> 445 N SAN JOAQUIN, PHONE (20 ) 20 Naafi <br /> P O BOX 2009, STOCKTON, C <br /> Ai <br /> PERMIT EXPIRES 1 YEAR FROM D ED <br /> (Complete in Triplien q7&7 <br /> !t`111 the oxit rra] <br /> Application is hereby made,to San Joaquin County for a permit to construct an or inata <br /> fill <br /> application Is made in compliance vlth San Joaquin County Ordinance No. 549 and—t862- -5T-7&'n <br /> Joaquin County Public Health Services. <br /> ® 1 'n � _ ret' <br /> Job Address (JI <br /> .�� ILY�� /� [� City ,'ccy� Lot Size/Acreage <br /> r � �� j �7 <br /> _ Owner's Name �0�'l � rAddr,e�ss /y�� „/�,/�� ���,Phone ^�J <br /> Contractor+ Address P:-77J E ALZ= /sl�-icense No�,-s_. < =-Pro ne / <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well ❑ <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 /> C1Industrial ❑ Open Bottom ❑ Mameca Dia. of Well Excavation Dia. of Well Casing <br /> C.1 Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing-_ Specifications <br /> I'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by r� <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION If REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feel) <br /> Installation will serve: Residence-eK- Commercial_ Other <br /> Number of living units: J— Number of bedrooms / <br /> Character of sell to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl �1�, Method of Disposal <br /> Distance to nearest: Well R-�= Foundation Property Property Line <br /> Asa <br /> —' LEACHING LINE X No. 6 Length of lines - Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line V <br /> _ SEEPAGE PITS Jf Depth / 'tile <br /> SUMPS <br /> y�7L mz Number <br /> SUMPS LI Distance to nearest: Well 2rnFoundation _lan , Property Line_ <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> r rules and regulations of the San Joaquin County <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 hiring 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/must call for all re i ed in pe ions. Complete drawing on reverse side. <br /> Sign a Title: (�kl 1 ho A Daro: !b �7 3 <br /> �" "�C'' FOR DEPARTMENT USE ONLY <br /> Applicstlon Accepted by Date �� Area <br /> &X <br /> t Grout Inspection by Date�� j Final Inspection by etal <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 Boz 2009, Stkn, CA 95201 <br /> "r��/ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT NO. <br /> INFO / /^� ))/�/J��} ./l /� /� ✓/ /JJ .( Jn�� <br /> —. EH 1I-1t IaEV.rrxers / , G,v /�, 'LIVJ/ '13 5V � /6 / 7J �✓ �v <br /> EM lr->0 <br />