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07-14-1995 09:50AM FROM TO 14084417539 P.01 <br /> _ SAN•AQUIN COUNTY PUBLIC HEALTH &VICES 3p57 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> !' 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O SOS 2009, STOCKTON, CA 95201 <br /> i <br /> PERMIT MIRES 1 YEAR FROM PWk ISSUED <br /> (Iomplete in Triplicate) <br /> A�Plicatlon 1a �ereby t6 San Joaquin Cotttyty for a Permit to construct and/or instill the vera berein described, this <br /> application. is taide in ccMillance cith Sao Joaquin County Ordinance No. 50 and 3,862 a»d the Rules and Regulations of Saa <br /> Jbaquln County Public HoolthServAces. { <br /> i <br /> 4,110 Address 1( i r I City `•'/K'k � Lot Size%Acreage <br /> she I m i f'D Bax �yy> Ca �o/d <br /> CIIlOnntaraicalN.a.n.e i Adtl ,Phone $`�b <br /> f1yW <br /> or 7Address Zr+ +o� -�t <br /> + <br /> :phone <br /> TYPE OF WELL/PUMP: NE' WELL ❑ I WELL REPLACEMENT O DESTRUCTION 0 Out of Service Well ❑ <br /> i PV PINSTALLATION SYSTEM REPAIR ❑ OTHER Q Monitoring Well <br /> .DISTANT TO NEAREST: 'SE TIC TANK � I SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FO JNDATION( mfLlf-AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> \ TENDED USE T PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 14 h, <br /> rl-tndustsial j O pen Bottom O Manteca Dia. of Well Excavation l Dia- of Well Casing cA <br /> .. . .bornestic/P.rivate C7 r'avel Peck i Q Tracy Type of Casing'� 40.i,PVb Spout ications--�D� 5rrce.-I <br /> P 'Public 11 Pat n Delta Depth of Grout Seal D^t{ Type of Grout N dO{ dsmcnr (/` <br /> ' '1'` Irdilation. .; I 54 Apprcx, DI pin 1 I Easiarn Surface Seal Insulted by <br /> „.J( a Work Dona. . L7 Ty of Pump IH.P,. State Work Dano <br /> ., I sealing Material a Depth <br /> If Destruction I..O, :_Will <br /> Diameterr. <br /> { .. .Piller Material i Deyoti . . .. ... <br /> TYPE OF SEPTIC WORK: NE INSTAILATIONi ) REPAIR/ADDITION 1 I DESTRUCTION I P (No septic system permitted if public sower is <br /> : I available within 200 feet.) <br /> Installation will serge:.•Restd motor t T.'. . <br /> Number of IIVmg units: Ni 081t-W Fax Note -7671 Dat hof► <br /> �harseter o/sod Ito a depth tj 3 11 To! I From fie depth <br /> SEPTIC TANK i - 4 /I a ,jCo oanments <br /> kG.TREATMENT.PLT:O i 'J Disposal. <br /> Iat,, Phone a U i Ph a — yr/ <br /> W <br /> I pp <br /> LF�CHING LINE ❑ P q. H t <br /> FILTER BED . . ., . . <br /> I L7 tstan ; ' , . . <br /> SPAGE PITS 1 I Debut Slit Number <br /> SUMPS LI, 13 istaticat tq nearest: Well FoundationProperty Line <br /> 1'hpreby cenity than 1:have prep teci this ip�lieation and Coat,the work will be.done in accordance with San Joaquin county ordinances;state laws,'and- <br /> 'rlu and'rdgulaeons o/'The seeJoaquin,county <br /> Moyne owneror ficeivred!agent's signature'o�rtHis,the following: "I conify that in the performance o/the work for which this permit isiigaued, 1 snail net--' <br /> arr�pfoy any person moll men eras to b�agoma subject(p workman's compensation laws of California." Contractor's hiring or sub•contiacting signature <br /> so�lifies the following:'9 county fiat m the,Psrfor..0 cis of the work for which this permit is issued,,l shall employ persons subject to workman's compensa- <br /> tl'oi1'laws of Cbldorni0.°' I <br /> The applies call.lor as biro pi etions,_Com pete drawing an to e a sod <br /> SignadYL;G`-Title: � �/ Date: <br /> .I FOR DEPARTMENT USE ONLY - <br /> Apg11"don Accepted by' bate r¢ �S Area <br /> I •"I <br /> PitGrout tmpeetion try 'Date Final Inspection by <br /> rDace <br /> �i <br /> Additional Comments: l —;L ! <br /> Applicant - Return al C001e1 to: San Joaquin County Public Nealtli serviggs <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Rog 2009,! Stxn,,CA 95201 <br /> i I <br /> ! INFO AMWN14btiE AMOVNT REMITTED CASH RECEIVED !Y DATE PERMIT NO. <br /> yy see /q <br /> 13.24 lnEV.v.er <br /> 1 Nets j <br /> I <br />