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07-14-1995 09:51AM FROM <br /> TO 14084417539 P.02 <br /> 4ebyd <br /> qua <br /> duo-1.11 t Mi'l'l Yu"Llu bzAl-'lil J (�F:S <br /> IRONMF,NTAI, HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PRONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 �?� <br /> kms!/ l <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> l (Complete is Triplicate) <br /> Appl;<atloa madd, 'Ean Joaquin County xor n permit to construct sae/dr install the work herein described. Shia <br /> appl cationin cospl wee vitt) San Josula County Ordinance No. 549 and 1862 acrd the Rules sad Regulations or San <br /> Joaquin Couc R slth Seritiilceia.„ 'I ICityL”" ) Lot Eize/Acreage <br /> Job dress y�/+,Owne4 a Nam6- ji Address Phone wo <br /> l eox <br /> j7r)l Address Pp'�X ZZ3 q S?4� License No. !0"]2l0�7' PhoneFYPE SOF WENEW WELL _ WELL REPLACEMENT r DESTRUCTION O Out or Service Vell ❑ <br /> jPUMP I STALLATON g fSYSTEM REPAIR O OTHER O Monitorri_ngg Well LO <br /> ))STANCE TO NEAREST: SEPTI TANK SEWER LINES U DISPOSAL FID.. PROF. LINE <br /> FOUN ATION AGRICULTURE WELL OTHER WELL-&A— PITS/SUMPS. <br /> IN'ENDED USE TYPE F WELL' PRORLEM';AREA CONSTRUCTION SPECIFICATIONS N <br /> Ind spial ❑ OpoLPackO <br /> anieep Dia, of Well Excavation Dia. of Well Casing <br /> 'l Do�estic/Private 0 Graacy Type of Casing1 SpecificationsPutllIlic MOrst(v"t✓rqI:1Othelta. Depth of Grout Seal g Type of Grout'pm� n�{Irripatien 1JL Astern, Surface Seel Instannd bVlepeir Work Done L-1 Type oH.P. State Work DeneNell struction OI Well O 'Sealing Material b Depth <br /> M� <br /> Filler Material i Depth Depth <br /> YPE OF SEPTIC WORK: NEW I STALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I P INo septic system permitted if public sewer is <br /> � - available within 200 feel.) C-r <br /> InstaIllation will serve:'. Resident — Commercial_ Other <br /> Number of living units: umber of bedrooms <br /> Character of wit to a,depth of 3 Vol: Water table depth <br /> EPTIC TANK 0 Type Mfg Capacity No. Compartments <br /> KG. TREATMENT PLT.CI !i i Method of Disposal <br /> Dista ee ro,nearpst: Well 1 Foundation Property Line <br /> EAC NG LINE 0 No. Length of lines Total length/size ' <br /> ILTEH BED i 0 Dista to to nearest: Well Foundation .Properly Line <br /> `I <br /> EEPAGE PITS I I Uect Sire Number <br /> UMPS LI Dista ce to nearest: Well Foundation Property Line <br /> ISPO$AC PONDS EI <br /> hemby certify that I have prepared this application and that fhe work will be done in accordance with San Joaquin county ordinances, state laws,and <br /> des arjd regulations of;the San Jo quin County <br /> ome owner or IiGensedl,agent's sig ature certifies the following: "I certify that In the performance of the work fon which this permit is Issued. I Shall not <br /> nploylany person in such rhanner a to become subject to workman's compensation laws of California.'!Contractor's hiring or sub-contracting signature <br /> trtifieq the following;");certify that the performance of the work for which this permit is issued,I shall employ persons subject to workman',compansa- <br /> sn qts of California."' <br /> to ap Gcant,, II fora ra uir d ins ti n CompI a drawing on r�ay/grad s-de.��,, ^'7 ��,5 Y ��L.f['/U I Data: / /Wghee � title: <br /> FOA DEPARTMENT USE ONLY °v <br /> pplicaiion Accepted bYl Date : �s Area ✓`�"o �=-^ <br /> [,or Grout Inspection by Data - Final Inspection by Date <br /> III <br /> iditiofpI Comments: <br /> Applicant - eturn all a pies to: 'San Joaquin County Public Health Services <br /> Environmental Health permit/services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA;95201" <br /> FEE <br /> INFO AMOUNT OUIE AMOUNT REMITTED CK H RECEIVED BY r� p(A/TE PERMIT NO. <br />