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7:-.7t/77*•-•,, <br />.1r <br />! <br />Job Address;15.2S-61". 0.-L5-141A1/4-72,/t.i )3Z/../.0 Cit 5-7-4Ck-Thd_./ Lot Size/Acreage S <br />- <br />01 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br />445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95 <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 2009, STOCKTON , CA 95201 <br />(209) 468— 3420 <br />PERMIT EXPIRES I YEAR PROM DATE ISSUED <br />(Complete in Triplicate) <br />hereby made .to San Joaquin County for a permit to construct and/or install the work <br />made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules <br />Public Health Services. <br />Application is <br />application is <br />Joaquin County <br />P,O. ex 2, X.57.704 d <br />Owner's NsmeTW EPS/ t)F C4-1 1--- Co. Address pi ucrsiS e cA. 92c'7 Phone(brej 4,63.. (4 0-; , <br />Contractor ) +0 D riVh yvi Address ?:_LIA1.(2j26 -t-a..- License No SB 7& Pho4/6 i 6,3/-7 /6 S-1 <br />TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT El DESTRUCTION 0 Out of Service Well 0 <br />PUMP INSTALLATION 0 SYSTEM REPAIR Cl OTHER 0 Monitoring Well A <br />DISTANCE TO NEAREST: SEPTIC TANK 4/1/4 SEWER LINES 2. 7 1 DISPOSAL PLO. Al4 PROP. LINE Me <br />FOUNDATION 7Y' AGRICULTURE WELL OTHER WELLV_ZZ___ PITS/SUMPS 41/4 ,/1//A <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation H Dia. of Well Casing <br />O Domestic/Private • • g Gravel Pack 0 Tracy Type of Casing 2 " PiCf574( L.- Specifications C.c. )4 40 <br />x P-t-tie 0 Other X Delta Depth of Grout Seal Si.,"2,t=-7ACZ Type of Groutritii<c/r- .40000-012- <br />C.1 Irrigation 251 Approx. Depth 0 Eastern Surfce Seul Installed by Cok_7724-c rojz- <br />Repair Work Done 0 Type of Pump H.P. State Work Done <br />Well Destruction 0 Well Diameter Seeding Material & Depth <br />Depth Filler Material & Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br />available within 2C0 feet.) <br />Installation will serve: Residence Commercial Other <br />Number of living units • Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. 0 Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE 0 No. & Length of lines Total length/size <br />FILTER BED 0 Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS 0 <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin County <br />Horne owner or licensed agent's signature certifies the following: "I certify that in the perl ormance of the work for which this permit is issued. I shall not <br />employ any person in such manner BS to become subject to workman'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 persons subject to workman's compensa- <br />tion laws of California." <br />The applicant 7 <br />Signed X <br />all req ired in -pections. Complete drawing on reverse side. <br />Title: <br />II <br />DCe <br />FOR DEPARTMENT DEPARTMENT USE ONLY <br />Application Accepted by 777 Date Area <br />Pit or Grout Inspection by (Date //- (V Final Impaction by <br />Additional Comments: <br />FEE <br />INFO AMOUNT DUE AMOUNT REMITTED CK i <br />CAsH RECEIVED BY : ,TE PERMIT NO. _ <br />-T .......7 c-1 -c), c---\ 6,i4p7 ----7,,.,4, ft-ic;,--1/ noq?oti- <br />Applicant Return all copies to: <br />r 2 11294 <br />_-1AJH <br />:CES <br />herein described. This <br />and Regulations of San <br />D a t e