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FP _ ;•1 _ f.'I 19/171 121 1192 10: 18 F'. 1 <br />! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> fit. CL' -�^�`�" ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 /0•� <br /> P -0 BOX 2009, STOCKTON, CA 95201 <br /> pgEm11 R7[ _ BRS 1 XSA IRON DATE ISSUED- <br /> (Complete in Triplicate) <br /> A"liastien is hereby 0"A.to taw Joaquin County for a permit to construct and/or inatall the work herein described. This <br /> E sppliaation is rade in eckvit ance vith i3An-Joaauin County Ordinanee no. 3L4 and 1062 and tht kulao s.ad Regulation■ of Ban <br /> Joaquin County Public Health Services. <br /> es 7U 3 dC/ �G lyV4!-r(/-C C yS>!�C M Lot tai Acreage <br /> Jab Addr <br /> III �d n Bei/r4*.rePi e d/ran e�i.r�i.e.tr✓i..e� <br /> rlaGcr Addraaa ,S7 SLtir q o Phone 772 3 <br /> k owner's Narne <br /> Conl+aCtor <br /> o r-1 Address �� el y UHC' License No.G_r7 779z3Pnone 2e9 FF7 <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCT ON YI 17ut Or Service Well W611 <br /> E� I PUAAP INSTALLATION ❑ SYSTEM REPAIR C1 OT ER 0 Monitoring L) <br /> DISTANCE TO N€AAEST: SEPTIC TANK SEWER LINES OISPOSAL PLO. PROP. LINE <br /> POUNOAIION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1NTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial 0 Open Bottom ❑ Merttecs OIs• of Wan Excavation Die. of Wait Casing <br /> Specifications <br /> Type of Casing.. <br /> OomsaticlPrtwte: Cl f3ravdi Peck O Tracy T Y <br /> I•M Pirhiic I�1 Other f7 Deite <br /> EE Daolh of Grout Seat typo of Grovt <br /> I <br /> I t trriunflon 71L Apt;rax. Ospih 11 Eaattrn Surflcl Saut Instaued by <br /> Repair <br /> Work Done !`U Typo of Pump H.P. State Work Done <br /> weft Otttructtan €1% W611 Olarrrerat ?"' I• ' Sealing Material & Depth <br /> I Depth 29 riller Hatarl.41 i Depth <br /> TYPE OF SEPTICW�1RK; NEW INSTALLATION I I REPAIRIADDITION 1 I DESTRUCTION t 11No taoItc system per—hied It p,rbrc sower Ia <br /> available with n 2170 feet-1 <br /> installation w411 aerYa: Rts4dence ...r Commercial Other <br />'E Number of living unita; Number of bedrooms <br /> i Character of tog Ib a daplh of S 1441- Water t bis depth <br /> SEPTIC TANK ❑ TypalMl9 Capacity No. Coo r1partmitnott' <br /> PKG. TREATMENT PLt.n Method of Disposal <br /> Distance to ne/rtit: Watt Foundatlon Property Line <br /> LEACHINd LINE 0 No. A Length of lines total length/girl <br /> FILTER BED n oisteoce to nearest: Weir Foundation Property Line <br /> S€EPAQE PITS it Depth Slts Number <br /> SUMPS I L'I Distance to neartat: Well Foundation Property Lin <br /> I <br /> DISPOSAL PONDS ! ❑ <br /> I hereby eartily that 1 have ptspafed this epptieation and that the work will be done in accordance wilh San JodQ In county Ordinances, atste laws. and <br /> rules and rtgularioni of the Sen JOeaulr4 County <br /> Homo Ownst or Ileerisod agent's ilgnature ctrtifeta the following: "I Certify that In the perlormence of the work for which this permit to Issued, I shall not <br /> employ any porion fn Such mafintr it to beeo+r+e cubit o workman's comperuotton laws of Carrotn!i.' Contract r'a hitlnd or tub-contraeting signature ^ <br /> a: „ p y p aoha tubihet to workrntn's eornp}neaO <br /> esrtiriea the foltowin I eertilY that In ihfa perforrnAnc o the work forWhich this psrmtt a lnutd, 1 shad employ lion low$ of California." - P g-+3 (— z P(11�fJf(/!r) <br /> The appllCahl must 620 for all f"ulr ct4 n rat two. <br /> Title: <br /> Signed G.rru✓Fn i/f�r/r t��o� I t Date. <br /> j'oQ � G• 6r.e �/0 442 s/FOR DEPAATMEAIT USE ONLY <br /> Application Acceptetl by Qete q z r �� Arte C• O <br /> Pit or Grout inaptetbn by Date <br /> Final Inspection by Oele <br /> Additional Corttmanta. 47y%___5 otp_ ��''yr�A- U - If moJ <br /> Applicant - Octurn all cogiee to: In Joaquin County Public Health Sery iii �jL/Q'Lit� 61't" <br /> $nvl#oomental Health Permit/Services / <br /> 445 N Sao Joaquih, P D Soft 2000. Stkn, CA 6$201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C,KS*,4 RECEIVED AY OA E PERMIT,No 1 <br /> INFO /! q <br /> CMr3,24uMtV,,�■a, � GDI 6 5 !�f Y5 �4� 9 q�•'3G+ a��r <br /> ew .Tt O I <br /> 1 <br />