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r. <br /> fa <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> elf P O BOX 2009, STOCKTON, CA 95201 ? <br /> PERMIT MIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby esde to Bao Jeaq':Sa County fora permit t4, construct 54 had/or Install the uork herein destribad. Ban, <br /> syplleatloo L esde in Gal®llan__ with San Jwquln Cooney Ordinance No. Sk9 and 1862 and the Pulse aW PeEULtloaa of Ban, <br /> Justin, <br /> County���3lllPublle Realtn�errl:••. c '.8 <br /> Jo Scree /a-�S� L City Lot Site/Acreage <br /> vas <br /> _ r <br /> Owner'• It. o' - cix,,ca ai9 <br /> Canvact / dress <br /> r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [l DESTRUCTION LT Out of BerYlce Mall Ll <br /> PUMP INSTALLATION SYSTEM REPAIR , OTHER O mevitorial well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP.LINE Ef <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Indwuin ❑Open Bottom ❑Matlnoe Dia.of Well Excavation Du.of Wall Casing 3 <br /> (:1 p6mesticiP,tvati, ❑Gravel Pack ❑Tracy Type of Cesinp_ SW..I,cations <br /> public "-11 OIMr fl Datta Depth of Grout Seal TYy. n Gan' <br /> ` I .lupatbn _Apiaw.Wpt Etat n_ dace Sal Installe7vAthm <br /> Repair Work Done ❑ Type of Pump M.P.{�Well Datrunion ❑ WWDiameter �_ Sealing VAterlal A DepthOplh :31ler Material A Depthr TYPE OF SEPTIC WORK: •NEW WSTALLATIOM;I REPAIR/ADDITION I 1 DESTRUCTavaable 'rememW n Vutlia sewer isInstallation will si v : Residents_ Comnerc41_ Other <br /> 1Number of living units:_ Number of bedrooms iCh.,pnr of wit to a Moth OIO fest: e depthr SEPTIC TANK ❑ TypeIMfg CepaCiryit ent,PKG.TREATMENT PLT.❑ Dipoal i <br /> Distance to neater[: Wall Foundation Property Lire j <br /> LEACHING LINE ❑ No.A Length of time __ Total Mngrhhice__ _ S <br /> FILTER BED ❑ Distance to interest Well Foundation Property Line <br /> S <br /> E <br /> SEEPAGE PITS 11 Depth Sire___Number ' <br /> Property Line <br /> r f <br /> SUMPS U u <br /> D"once to neanac Well Foundation_ j <br /> DISPOSAL PONDS ❑ <br /> I hereby unite IMI I have prepared this application and that the wort will be done in accnravrca with San Joaquin county pdinentas.acne 4vn.and i <br /> rules and regulation.of tM San Joaquin County <br /> Home owner or hcensW spent'z signature cenifles the foMwing:"I ueifY that in the performance of ttta work for which this permit is issued.1 Nall not e <br /> r employ any person in such manner a to become what,to workmae i compensation Irm Of Calif0ma."Cnnt,actols hiring or suRconusainp signature <br /> cartiflo the following:-I coma,that in the performance of the work for which this permn is Iswad.I @hall employ"Isom subject to workman's company <br /> tion lawn of CWfornis.•• <br /> The appli r 1 st call fot)�ag r%��kJy Inspections.Complete drawings on eveyiiiA sine <br /> Dau: <br /> Bar <br /> AOr � R MEIIT USL .NLY <br /> Oats T `b Ana <br /> ApplicAnum Accepted by c _nn <br /> bo Pit a'Crwt Inspection by Data Final lrapecbenM '—� Dab _`2 <br /> Additional Comments. - —_ <br /> Applicant - Return all copies to: Sen Joaquin County Public tlecilth 5onlcea <br /> Environmental Health Permltt'SerylSea <br /> 445 N San JOaqu/n. P O Box 2009. Stkn• CA 95201 <br /> FEE AMLWNT Dug AM05NT REMITTED toga RECEIVED AY pATF PERMIT NO. <br /> .fM le.3e laN.ir .Il�e` Y�t OV I1 • 1- FYtan.,y��_41& -0—dV <br /> ea v.a <br /> V <br /> V <br />