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v <br /> SAN JOAQUIN COUNTY PUBLIC HE TTW!=ENVIRONMENTAL HEALTH DI I <br /> 445 N SAN JOAQUIN, PHONE (2 420 <br /> P O BOX 2009, STOCKTON , <br /> Aft PERMIT RES 1 YEAR R M i� <br /> (Complete in Triplic tINV # ILL h4o <br /> Application la hereby wade to Sen Joaquin County for a peralt to cont+truct en �v <br /> application is ade in Ccup <br /> ►lliance with San Joaquin County Ordinance No, 549 and 1862 and the Rules and RegulAtions or Ban <br /> Joaquin CountyCPu�blic, Health 8r <br /> evieee. <br /> Job Address _�� =' rp City C� Lot Site/Acreage r r� <br /> Owner's Name �� °� e ' , r�-L Address U S �1 Fhone I Z3—591 <br /> a <br /> Contractor Address <br /> r' in T �4 to P Q� aq License No.369-95L Phone <01-030 <br /> TYPE OF WELL/PUMP: NEW WELL )� WELL REPLACEMENT rl DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR -I OTHER ❑ Monitoring W'11 a <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ O� D� SEINER LINES -- DISPOSAL FLO. PROP. LINE dD <br /> FOUNDATION � �_ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S/ <br /> Cl Industrial ❑ Open Bottom L Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 69,00mestic/Private ilk Gravel Pack7 O Tracy Type of Casing---- 15pecificalions <br /> I'I Public 1-1 Olhy rl Delus Depth of Grout Seal t. '� Type of Grout <br /> I I Irripallon -74/ Approx. Depth Il Easlen, (Surface Soul Instai d by <br /> Repair Work Done U Type of Pump : Lub 'J H.P. r State Work Done <br /> We4 Destruction O Well Diameter Seeding Material i Depth f1 <br /> Depth Finer Material i Depth W <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sower is <br /> available within 200 1861.} <br /> Installation wilt serve: Residence__._ Commercial-___ Other <br /> Number of living units: Number of bedrooms <br /> Character of loll to a depth of 3 test- Water table depth r <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartrnenn <br /> PKG. TREATMENT PLT, ❑ Method of Disposal v <br /> Distance to nearest: Well _ Foundation _ PropertyLRA�■AM. ,2`C1 <br /> aoie- kv <br /> LEACHING LINE ❑ No. 6 Length of lines _ dotal length/siz If CC VP <br /> FILTER BED ❑ Distance to nearest: Well Foundation _ Property L14 f <br /> SANj(') ` <br /> SEEPAGE PITS I ] Depth Size Nu C 11��1L r b <br /> �f�i� <br /> SUMPS LI Distance to near►al: Well Foundation Prcoerty e-14AL r�`�Ai7i�nlyly�4 <br /> DISPOSAL PONDS 0 <br /> I hereby certify that f hove prepared this appfication and.thaf the work wili be done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that In the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to wotkmsn's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman'&compensa- <br /> tion laws of Californi " <br /> The appliceny t call for all required inpoctions. Clem et cawing on reverse side. 1 <br /> Signed Title; C441 Date-- <br /> FOR <br /> ate:FOR DEPARTMEhWUSE ONLY <br /> Application Acceptrzd by clnlDate I Z S Ar <br /> lie <br /> Pit o Groat .pection by CZA2 �a Final Inspection by <br /> Additional Comments: SG3 <br /> Applicant - Retur all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CR 95201 <br /> �c J <br /> �, INFO AMOUNmiE AMOUNT REMITTED C K H RECEIVED BY DATE NO, <br /> T' I <br /> -3 gfo <br /> Esq r37�fIREV,r�ner ` ���• ! I � `(�� <br />