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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ;fEALTII DIVISION 445 N SAN JOAQUIN, PHONE (209)468 ?0 .� p 0 BOX 2009, STOCKTON, CA 952, "F'RMIT ERPIRFS 1 YEAR FROM DATE ISSUED _/�,� (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This application is mads In compliance with Sari Joaquin Colmty Ordinance No. 549 and 1862 and the Rules and Regulations of Sari Joaquin County .�hPubliccHHralth Services. 17SI � t Sixe/Ac�re g Job AdlrelLj!�� 6' ^/ i / --I Gwn+r'e /1 y— Phone _.�r1�'7,_L6/��QL Contras a '�' 'd" ° '^"_ dress Q _ =L--License No f`-Ir113l"hcne TYPE OF'HELL/PUMP- NEW WELL O WELL REPLACEMEN) i DFSTRUCTION Ll Out of SarvtCe Well l� SYSTEM REPAIR O OTHER 0 monitoring Wall C7 - PUMP INSTALLATION _ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .-- DISPOSAL PLD. PROP LINE ,� 3 FOUNDATION _ AGRICNLTURE WELL _ OTHER WELL-- PITS_/_SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA 0_ONSTRUCTION SPECIFICATIONS C;Industrial O Open 0otIom O Mnrbca Dia.of Wail Euavauon__—_—.— Dia. of Well Casing f I Domestic/Private O Gravel Pack Ll Tracy Type of Casing- Specifications.--- I'I Public I''•Other Fl Delta Dapth of Gout Seal ___. _ pe rSf Grout iL i 1 Irrrdalwn /ADtuo•. Depths I I :+Item - Suit Seal trslllled by —_-- 4 Repair Work Oct'. La,/ Typa of Pump � H.P..___ `•k'e Work O.ne Wall Destruction O Well Diameter Sealing Material a Depth_— n Depth Piller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITICN i i DESTRUCTION i ileo upoc system pormrt ted d Public sewer is 0 / available within 200 1N4.) Insusatbrvr Reu n will aersonce_ Commercial_ ONst Nerrber of living unite-- Number of rooms CPar•Ctx of soy to a depth o1 3 last: — _—._Water table depth SEPTIC TANK O Type/Mfg — Capacity No. Compartrr,enta PKG.TREATMENT PLT.O Method of Ciaposal Distance to nearest: Well — "oundation Property Una LEACHING LINE 0 No. 8 Length o1 lines Torsi length/sue _ FILTER SED C 1 Olstance to has —,_, urK.eton—_ Property t.ine I _ SEEPAGE PITS 11 Depth _� Sita Number_____—_� — SUMPS LI Distance to nearest Well _ Foundation._.�. _— P'operty Lira .- 1 DISPOSAL PONDS O y1 hereby Comity that I hew pieosrod this application aria that the work will be done in icurdance with San Joaquin county ordinances,stab laws: and 9 rules and rsguiat, San Joaquin Ccwnty y Home owner rConssd.age 'a srgna Nte ceriifres tho following "I csm;fv that In the performance of tl•e work tot which this perrnit n Issued.I Mill not employ any son M such her as to become subje: orkman's compensation laws of California."Contractors hiring or sutftontrscting signature k certifies th I090 ing:"I Cam' that.n rhe .o:mane � s work lot which this permit is issued,I►hall employ persons subject to workman's compenar I tLn Laws I Call 1nis." The app cant m t or raquk a Ing on ✓t, r z� i! t e� Title•-- _� Dae: Signed X FOR DEPARTMENT USE ONLY R ApFliratinn Accepted by \moo >— Data 1-- Area— r n Date final Inapect;on by n,;) Da.3 II Q3 Pit a G;outlnapectbn by t, 4 Additional Comrr*nta' Applicant - Return all copies to: San Joaquin Couety Public Ilealth ServlceR ; ¢nsl ronmen u1 h permit/Sarvl eek I eS6 N San Joaquin, P O Sox 7009, Stkn, CA 96401 FEE AMOUNT DUk AMOUNT REMITTEDK RECtivID by DATE PERMIT 0,10. CASH f INFO e_ � 41� Ell EN 1}11(AIV.ire11 t t it? IN toy r IY C.' t ._....�.._. -Ch1'fit:+bik• YiI�F6: YLv'4VAfAT+14>;:Askrr's<.► 4sl,:kAxi+�-erim!.wvi,:s.R, ra;.artesAl.Ydi'a-"ar...•a..•.dn.�.•.•+�••+,••• t . I f. Y i v4.0 IS;`