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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 1 YEAR FROM DATE ISSUED <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 1n 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. <br /> +3 <br /> Job Address 6F_() it o � �C <br /> City � Lot Size/Acreage <br /> Owner's Name _ Address cAM Phone <br /> Contfactor.CLA GIZOTS Address A rJ W [7:r-,..._. License No, 7��dr-r Phane �YJ <br /> LX <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATIONS SYSTEM REPAIR 0 ,e-OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK f � SEWER LINES DISPOSAL FLDU-� PROP. LINE L_ <br /> FOUNDATION AGRICULTURE WELL: OTHER.WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'V <br /> Ll Industrial O Open Bottom O Manteca Dia. of Well Excavation - Dia. of Well Casing 6 <br /> )1e+,Domest ic/Private 9Specifications <br /> Gravel Pack Ll Tracy type of Casin _ 0 <br /> - --- � <br /> Il Public 1-1Othern Delta Depth of Grout Seal �.,� _ Type of Grout—C-. �j <br /> I I Irrigation 3"310—Approx. Depth l I Eastern Surface Seal Installed by ���- yi+ <br /> Repair Work Done 0 Type of Pump ­Uee— H.P. __ _- Z. __ State Work Done _CaA- S'x+e.• ill r� <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is n <br /> available within 200 teet.l <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedroomsQ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property rine <br /> LEACHING LINE Ll No. & Length of lines Total length/sire <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS It Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS o <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 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." <br /> The applicant must call for all required inspeptions. Complete drawing on reverse side. ` <br /> Signed )(_f �•r Title: Date: <br /> R D ATMENT USE ONLY <br /> Application Accepted by __OQ � •" -- W—1 Z ® f 3 <br /> --nn Date_ <br /> 'YArea <br /> Pit or PInspection by��+�/ Date�y�inal Inspection by �,- Date 10--t=12 <br /> Additional Comments, 1�n <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 y+ <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY �C <br /> 'INFO CASH DATE PERMIT NO. <br /> . EH 13.21 IREV.I/x S1 V\! 1017.4 <br />