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" P `` a i j- 'a'! �a 5r+ s i. .r r 1 r:� 1.."i- r� 4xvg 7'l,'�`."alb�.-f., -• a,1,.. w r}r� r �, -g-�-- i •�ir� f_ ,, ,ir 1., n�'4,s,.�. .ar..�A:S, ..+:.,1`:ir'r`.SW=la.�e�eePmq��..+�`w.Y. .: ��, .•,.Y/,5.�x,..�.,aw.4.�C`d*a.�?w x.:.r..+„wx: .�vs1.,,k..J_w�e.., - -u..,^. r�c� ivlRiaarlli iil v i illi 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 9520 ' 1 PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) d Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City ! Lot Size/Acreage 7- A/Z Owner's Name Its -'�-- Address SPIVPhone r - 2- ContractorL!i � Cyr� Address 1G� �` `-r`( c�"'// S-3 L13 License No. 7 � Z � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0TH onitoring well C7 ..i DISTANCE TO NEAR SEPTIC TANK SEWER LINES DISPOS PROP. LINE \ FO ION AGRICULTURE WELL HER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 08LEM AREA C LICTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing C 1 Domestic/Private 0 Gravel Pack ❑ y of Casing_ Specifications I'i Public l.) Other i Delta Depth of Seal Type �fGut I i Irritation _ A . Depth I I Eastern Surface Seal Instaile Repair Work Done ❑ pe of Pump H.P. Y State o ne [� Well Destruction ❑ Well Diameter Sealing Mfaterial 6 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR IADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is V available within 200 feet.) Installation will serve: Residence,G1.. Commercial_ Other Number of living unite: --L_ Number of bedrooms- ,fn Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK. X- Type/Mfg �rL Capacitya�e No. Compartments ;{ PKG. TREATMENT PLT. ❑ i r Method of Disposal Distance to nearest: Well Foundation _�� Property Line / LEACHING LINE No. & Length of lines Total length/size FILTER BED 11 Distance Distance to nearest: Well Foundation Property Line 10 SEEPAGE PITS Depth 5 Si.�s� Number SUMPS Ll Distance to nearest: Welli��-} Foundation�l C1�F Property Line - , _ 0 DISPOSAL PONDS ❑ I hereby cgrtify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and,?regulations of the San Joaquin County Home o?tiner 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 employany person in su nne s to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the f i sertity thLntheerfor nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ^tion la Calif nia. ' The ppficant m cal o reG on omp etedrawing on r verse side. 0 Signed Title: ��fn Date: FOR DEPARTMENT USE ONLYT/ Date A Application Accepted by Area Pit or Grout Inspection by Date f Final Inspection by P ` Date Additional Comments: r � t `l D - t-2 t� Applicant - Return all copies to: San Joaquin County Public Health Service Environmental Health Permit/Services ilk 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE n�{ AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. JNF. CASH EH13-24IREV.1iM5t /� JI • ' 1 .cz E'i 14-26