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+}!r .ii- `�- �.. ♦fur a;,sw <br /> SAN JOAQUIN COUNTY .PUBLIC HEALTH SERVICES <br /> j ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, ,�PHONE (209)488-3420 <br /> { P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES ,-1 YEAR FROM DATE. ISSUED <br /> (Complete ,in„ Triplicate) ­ 411 <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'Regulatione of San <br /> Joaquin.County[[Puublic Health Services. <br /> Job Address � V �l a- �' _ City Lot Size/Acreage <br /> Owner's Name lzA O Address 'V415 b I& W�l�j Eln2A /&/Ohone <br /> ContlactorrrEn S It[fh 5. Address L/ icense No. 7-7— Phone77 - <br /> F TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION o Out of service Well ❑ <br /> - PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well El <br /> DISTANCE TO NEAREST: SEPTIC TANK -�f ' SEWER LINES DISPOSAL FLD. PROP. LINE s <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> L7 Indd rias pen Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casin <br /> (!1'Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing� _ Specifications <br /> Il Public El Other 11 Delta Depth of Grout Seal r Type of Grout11 Irrigation ACT' 2LLlApprok.:Depth I I Eastern Surface Sedi Installed by <br /> i <br /> Repair Work Done 0 Type of Pump H.P. L' State Work Done <br /> Welt Destruction ❑ Well Diameter r ' Sealing Material & Depth <br /> i , <br /> j <br /> Depth `@ r Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAODITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet) <br /> Installation will serve: Residence_ Commercief Other <br /> Number of living units: Number of bedrooms <br /> 01 <br /> Character of sail to a depth of 3 feet:t �` Water table depth R <br /> SEPTIC TANK 0 Type/Mfg. ' Capacity No. Compartments 11�U <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal XZ11 <br /> ' - * -Distance-to nearest: Well Foundation Property Line <br /> t Z I� <br /> S <br /> LEACHING LINE ❑ No. A Length of lines Total length/size A <br /> FILTER BED �r E) Distance,to-nearest: Well Foundation Property Line <br /> SEEPAGE PITS I Depth ' % Size -Number # <br /> 1. SUMPS LI Distance``to dearest: _ Well T Foundation Property Line-/-- <br /> DISPOSAL <br /> ine-s —DISPOSAL PONDS 10-•'”" - 'I 1 <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 /> F Home owner or licensed agent's signature certifies the following: 1 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 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." it <br /> G The applicant must call for squired inspections. Complete drawing on reverse side. , + <br /> ;l <br /> Signed Title: Date: <br /> 4 FOR DEPARTMENT USE ONLY � <br /> Application Accepted by _ t - -- Date Z_ Area / <br /> Pit r u spectian by DateB Final Inspection by Date y <br /> Additional Comments: .41 n <br /> f � <br /> Applicant - Return all copies to: San Joaquin County"Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE,4 AMOUNT REMITTED I CK -RECEIVED BY DATE PERMIT"No. <br /> INFO �r� CASH r 9 <br /> . EMIi•2sIpE '" <br /> EH 11.2E V.1iKSY � 139,061 <br /> Vd 4 O L/33 <br /> `�^� � qZ•�/ <br />