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)570r2 petitP /MSTA(_(,A'Tlo") 014LI 1Xf A IVGk1 &,,,� �S• 't <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 3 YEAR FROM DATE ISSUED i <br /> .__ ,- —.- -(Complete in Triplicate) <br /> 3�- f �S�—f DO -f�2 <br /> Applicatiaa is hereby made to ran 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. 51+4 and 1862 and the RulesandRegulations of San <br /> Joaquin County Public Health Ser ces. p l <br /> Job Address _ s_� C- _ V ____/ A�-� City�^+ Lat Size/Acreage O �IG <br /> r ! l <br /> SAN J� tJIN �LII� <br /> Owner's Name LN-:9 <br /> Phone y <br /> Contractor i.7j+�1"� S V* Add,,,, U 2-:9 /�/OSC E�t,�icense No.q 1eL Phones <br /> TYPE OF PUMP: NEW WELL T ❑ 8fi6;rR QZI.iAJ Ll Out ❑ <br /> PUMP INSTALLATION .9409 JeRAIR ❑ 0"*R 0 ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANIvea-d // _ SEWER LINESQ✓HT.L-* DISPOSAL Ff_D.. PROP. LINE <br /> FOUNDATIONOV161000 fAGRICULTURE WELL OTHER WELLl —�FTPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _> <br /> ' <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �JJ�} <br /> Cl Domestic/Private Gravel Pack7 ❑ Tracy Type of Casing .51Gel.- Specifications I <br /> Cl Public El Other Fl Delta Depth of Grout Seal Type of Grout---- <br /> I <br /> r uti I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by e L 42W— li.I�L C�2!`_(�[ <br /> ftepeir�AReFk-Ogne U Type of Pump ]�W� H.P. <br /> /� State Work Done A1sTRLL tlMp <br /> ❑ Well Diameter Sealing Material & Depth r <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I R PAIR/ ODITION f I DESTRUCTION I 1 INo septic sys[am permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial A dther n <br /> Number of living units: Number of bedroom <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfga city No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method or <br /> pff <br /> Distance to nearest: Well Foundation Property Line @ g E D <br /> LEACHING LINE ❑ No. & Length of lines Total length/size �! <br /> FILTER BED t7 Distance to nearest: Well Fi at Property Li d CO'J QTY <br /> ��JJ <br /> -RV <br /> iCE.' <br /> F <br /> SEEPAGE PITS l I Depth Size Number HEALTHUN�011J'11 <br /> SUMPS LI Distance to nearest: Well_f0tio Property Line <br /> DISPOSAL PONDS ❑ `J - <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 /> 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> tion les the followin "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 la <br /> The apple t m t I r all required ins tions. Complete drawing reverse side. <br /> Signed X Title: �JSTR.ut..'�'ttj, ,,,_.L`�1f�d�"— Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Z' o Area 2� <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: an Joaquin County Public Health Services <br /> E ronmental Health Permit/Services <br /> 445 an Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT <br /> JDUE AMOUNT REMIT-TED CK S ASH RECEIVED BY DATE EPERIMIT'NO.C9 C) 4f <br /> EK 13.24(REV.�ixsi s,✓ ` �� f �` .�4.20 V �/l/�J <br />