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Lai APPLICATION <br /> SAN JOAQUILN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT =IRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin county for a permit to construct and/or install the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 1(.. <br /> Job Address C �' 1 � �N 1mCrn Lc y1 ;:.:v C� �`1'I :.or, Sizei Acreage <br /> Owners Narne E`1NF,Vl l/1'Iu JGnuj TI,�S r-F Acaress �LZ4 �Cc{ # (ZSZ Phone <br /> 1 <br /> Contractor <�Jtl�� �nv�c�t�wJPyt/4r ( �aoress � ao X Igj�t�CY1tCci.�� /�4Sf0 _cense Na, e' 5 SSZIyj P�one��cF�f4S'2`�ZL <br /> TYPE OF WELL/PUMP: NEW WELL Z: AIELL REP!ACEMENT 7 DESTRUCTION E7 Out of Service Well <br /> PUMP INSTALLATION C SYSTEM REPAIR OTHER` Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICL.'LTURE WELL OTHER WELL PITS/SUMPS _ <br /> ;INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> industrial 0 Open Bottom a Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domesticr Private 0 Gravel Pack 0 Traci Type of Casing_ Specifications <br /> Public f-1 Other II Delta Depth of Grout Seal Type of Grout C'e ° '� PK "ir <br /> irrigation _ Approx. Depth i Eastern Surface Sear Installed by <br /> Reoarr Work Done -L3 Type of Pump P - State Work Cone _ <br /> Weil Destruction 0 Well Diameter Seaiicg Material 3 Depth <br /> Depth -_1:er Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION , RE?AiR:ADOITI0N : DESTRUCTION-I . iNo septic system permitted if puoliC sewer is <br /> avarNple within 200 fest.l <br /> Installation will some: Residence_ Commercial_ C;her <br /> Number of living units: _ Number of bedrooms <br /> Character of sod to a depm of 3 feet: Water table depth <br /> SEPTIC TANK 0 'vpe/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. C Method of Disposal <br /> Cstance to nearest: :,eii =ounaation Property Line <br /> LEACHING LINE CI No. d Length of lines Total Iengtnrsize , <br /> FILTER BED 0 Cstance to nearest: well Foundation Prooertv Line <br /> SEEPAGE PITS I I Depth Sae Number <br /> SUMPS LI Distance to nearest: Was Foundation Property Lina <br /> DISPOSAL PONDS C <br /> 1 hereby certify that 1 have prepared this application and ,:at ins work Wiil be pone in accordance with San,Joaquin county ordinances, state laws. and <br /> rules and regulations of the San Joaauin County <br /> Home owner or licensed agent's signature candies the foadwing: 'I Certify that in the performance of the work for which this permit is issued, I shall not <br /> smmosdy any person in such manner as to become sUblect to workmen s compensation laws of California. Contractor's hiring or suo•contract ng signature <br /> candies the following: "I certify that in the performance or trio work for which this permit is issued. I snail employ persons suolect to workman's compensa- <br /> tion laws of California." <br /> The aodrcant must call for all required inspections. Cornoiete arawing on reverse/side. ''// <br /> Signed X - Title: �y"�-- Gec-,(( P <br /> � is 4- Date: /Z Afq <br /> — J { l <br /> FOR DEPARTMENT USE ONLY <br /> ©vim <br /> Application ACteO[ad by '"C_'� " 'o-",+ Date / ` Area <br /> Pit or Grout Inspection by ::Ata4!! Final inspection by A7� Data �'� l <br /> Additional Comments: .21 11621KM-�----- - -- <br /> ApPli�ant - Return all copies to: S n Jcaquia County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT PE.MiTTED CASH ; RECEIVED BY I GATE PERMIT NO. I na'Ye 1�-4 <br /> .Po -C,6 ?37P Me �'/ 0s9y,3 ' <br />