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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 j <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II <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 is mde in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County'��Public <br /> Health Services. <br /> Job Address Lot Size/Acreage <br /> 72 - OO <br /> Owner's Name 1 r t,f�Y VM 1/�A^d�TdreRs "�[ Phone <br /> C9ntract Address LSC '1r'�7/9 License No. Z Z Z& Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Sl DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ . <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS +.t <br /> O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing <br /> Domestic)Private EI,4S`3v_el Peek^ O Tracy .Type cd Casing_ - ` Specifications <br /> I'1 Public I.1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I Irrigation ADproxrbeplh 1'1 Eastern T'"` Surface Seal Installed by <br /> Repair Work Done U 'Type o1 Pump H.P. State Work Done _ O <br /> Well Destruction D Well Diameter <br /> Sealing Material i Depth <br /> Depth ,-11 Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR ADDITION I I DESTRUCTION I I INo septic syslem permitted it public sewer is <br /> available within 200 feet.1 WWW <br /> r <br /> Installation will serve: Residence.— Commercial Other <br /> a� �`Numbei'dl living umii:=L""'NQi1!KdTtit; fr ms <br /> '" ater table depth <br /> Character of soil to a�dap/1h of 3 feet: OO <br /> SEPTIC TANK,-, 1 ; Type%Mfg IY. - Capacity No. Compartments <br /> PKG. TREATMENT PL{Ll- .1 r��/� / Method of DisWul <br /> -r Distance to nearest: Well X6`0 Foundation �O t Property Line -5 7 / <br /> LEACHIN_eI1INE ' No. 8 Length of Sines "- /� Total length/size <br /> FILTER"BED n Distance to imaresc Well �Q'{' Foundation �O '� Property Use` T f <br /> S - ➢lumber l <br /> SEEPAGE PITS Depth �' - Site�. <br /> SUMPS LI Distance to interest: Well Foundation jU 'f Property Line S �' <br /> DISPOSAL PONDS O <br /> 1 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 cenifies the following: "I candy that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such menneras to become subjettto workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cenify'that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa <br /> lion laws of California." <br /> The apptican i call I!M�Ilfed ections. Complete drawing on reverse sidSi <br /> Signed k Title: SS/��J Oats: <br /> �4t, -4i�Flov <br /> DEPARTMENT USE ONLY , <br /> Application Aotepled by a ' ! Date 'Area <br /> Det <br /> � Pit Grout Inspection bye _ - .Date��.5 Final InaPetGon by <br /> - <br /> I - e <br /> Add'nlonal Comments: <br /> Applicant : Return all copies to: San-.Joaquin County Public Health Services f <br /> Environmental HealthPermit/Services <br /> - 445 N San.JoaquYn O Box 2009;_Stkn, CA 95201", <br /> FEE AMOUNT.OVE _, __ AMOUNT REMITTE6 K 11 ECEIVED By D TE PERMIT NO. <br /> 77/1 <br /> D� <br /> Ell tI 1111W.11-s i <br /> Ell 14-38 <br /> ! <br />