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}� ;SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> '~ ' ENVIRONMENTAL HEALTH DIVISION <br /> 445 N -SAN JOAQUIEN• PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <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 with 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 f `� ' e'1a1IrVAeSe City Size/Acreage <br /> I <br /> Owner's Name rF��du C dress ii�1✓ Q��+ 0��r , rPhone 9L�Z <br /> ` Contractor ��� ass l ` � License No.l6��Phone 6 6.z <br /> I .��.�r.,._ ,_!]—License <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION El Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR i=1 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of ell Casing <br /> fl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Spec+iearions <br /> t'1 Public I:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I ) Irrigation Approx., LI i Eastern S e Seal Installed by <br /> Repair Work Done ,Type o} Pump � H.P. _ State Work Done QC ✓a <br /> Welt Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence^ Commercia Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to s depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ° � apaci ' No. Compartments <br /> PKG. TREATMENT PLT. ❑ l F r -- �° Method of Disposal <br /> � t <br /> Distance to nearest: Well Foutl ion . ' Property Line <br /> t,. <br /> 11 _ <br /> LEACHING LINE 0 No. & Length of lines " I " Ti;rai length/size <br /> ..,, .. <br /> FILTER BED 0 Distance to nearest: W 1) t "� Foundatior '`' Property Line <br /> SEEPAGE PITS 11 DepthfS _ Number <br /> ' SUMPS LI Distance to nearest ell r .) <br /> kFound qon Property Line <br /> 1 DISPOSAL PONDS ❑ I <br /> .r' <br /> I hereby certify that ! have prepared this applica Io "and that the work willb� done in a ordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County ; <br /> Home owep <br /> is signature cert lies the following: "I certifi th t in the performance of the work for which this permit is issued, 1 shall not <br /> employ anch ner as to become subject t orkman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> III certifies thcertif that in thOrman the ork for Ieh his permit is issued, 1shall employ persons subject to workman's compensa- <br /> tion laws The apptiall requ' ns. C plate awing on de. <br /> Signed Title: f1 Date: r <br /> TMiENT USE ONLY <br /> Application Accepted by Date yr / Area <br /> Pit or Grout Inspection by Date_ Final Inspection by Date <br /> i <br /> Additional Comments: <br /> Applicant .- Returniall copies to; San Joaquin County.Public Health Services <br /> Environmental Health Permit/Services <br /> F 445 N San Joaquin, ! O Box 2009, Stkn, CA 95201 <br /> i FEEAMOUNTAMOUNT DUE t1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> �l 3 <br /> . Eli13.24{AEV.rirS) <br /> EH t4•Ia C// /19JS <br />