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• ,LDPT.IC•m*nN • <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> IPPllcation 1s nereby made to San Joaquin County for a permit to construct and/or install the vorx herein described. This <br /> !Pplicaticn is made in cOmPilance with San Joaquin County Ordinance No. <br /> ,caquin County Public Health Services. 549 and 1862 and the Rules and Regulations of San <br /> .00 Address '✓ 0"f - Tra Gr� o�� ,SpH,`�, Chris,w Ll2 — c <br /> /T/fy/�J / �, ,�/y �'S�LV�___L� _ ��Lot Sl ze/Acreage %v-- <br /> OwneraName + *79, L 7jil7C t/J('�(((�1,,,,////// IILO,''f,G`V'IP M�j��/'Jf� <br /> A/ldress �art� Phone <br /> T a <br /> COntracmr (req ,4n StfU .4f <br /> 9 Address a415Cernt►sRytnMt, SigBa[H.0 C51- y85f� <br /> TYPE OF WELL/PUMP L�Brise No. 5 Phone 3M0�4t7-4d99 <br /> -�_ NEW WELL ❑ WELL REPLACEMENT 7 <br /> PUMP INSTALLATION ❑ DESTRUCTION L7 Out of rwell <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑q M&0`115 OTHER t Monitoitoringing Well <br /> SEWER LINES DISPOSAL FLO. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> "ITENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �ndustriai Opan Bottom <br /> Cumestiu Private 5Manteca Dia. of Well Excavation Mqc <br /> Gravel Pack Tracy Dia. Of Well Casing n�- <br /> Public Type of Casing_ 111PAL <br /> Other fl Delta Specifications <br /> ...gallon lQo-220 Depth of Grout Seal 1�1'Al dap <br /> ppox. Depth Eastern — ,1(PgyI Gr ut <br /> Repair Work Done G T Surface Saul Installed by �/'s^f121v'�y�i <br /> Type of Prox. H.P. kkk 1 <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> State Work Don <br /> neaterni2.A�g <br /> Depth —� Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION 1 DESTRUCTION II (No septic system permuted if public rawer is <br /> Installation will serve: Residence _ Commercial available within 200 feet.) <br /> Number of livingunits: , Other <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity _ No. Compartments <br /> Distance to nearest: Well Method of Dispoul <br /> Foundation Property Lins <br /> LEACHING LINE 1 No. i Length of linea <br /> FILTER BED ;-] Distance to nearest: Well C Total length/size <br /> undat:On PropanPs V Line <br /> SEEPAGE PITS II Depth <br /> SUMPS S1Sp Number <br /> LI Distance to nearest: Well <br /> DISPOSAL PONDS p Fountlabon <br /> Property Line <br /> I heresy comfy that 1 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 licans°d agent's signature certifies the following: "I certify that in the performance of the work for which this permit is <br /> employ any person in such manner as to oscome subject to workman's compensation laws of California." Contractor's hiring or sub-contract <br /> candies the following: P tss]rad, I shall not <br /> g: 'I certify that in the performance of the work for which this permit is issued, I shall employ signature <br /> non laws of California." p y Parsons subject to worker sued, <br /> tom <br /> The a - pause. <br /> applicant mus ca r I plf+ � a eti s. Complete drawing on r verse sided( ��/�n�_ /y <br /> Signed x �0 Br.�" Ni �I/GU a "! <br /> Title: � <br /> Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accaptep by <br /> Date S <br /> Pit or Grout inspection ov yL'N 1) � �' � J, Area <br /> y <br /> ate S Final Inspection by / -- S <br /> Additional Comments: Data <br /> Aoplicant - 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 <br /> `EE I >MOUNT OUE <br /> vF0 AMOUNT REMITTED CK RECEIVED BV <br /> �-t� CASH GATE PERMIT NO. <br /> EM I]241REV.lin ell W ` <br /> EN 14.20 111 T+ o I s 19S aasgs11 <br />