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SAN .; VIN COUNTY PUBLIC HEALTH :. VICES <br /> .It Co e , ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> d�r) `xP44 �� 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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health 9ervicee. �W �,�1/� J } <br /> Job Address �r" r Ci ,/ 4 vX('}� of Size/Acreage <br /> Owner's Name - r Address �, / �'� `— ' ��� (J,J�P�ho/n//ems �7T/ <br /> Contractor l �! r'f�f7f v" Address / l ( License No. 1 ///0�1/ A"r hone G--f <br /> TYPE OF WELL/PUMP: N W WELL WELL REPLACEMENT XDESTRUCTION ❑ Out of Service well <br /> PUMP INSTALLATI b, SYSTEM REEPAIR� ❑ OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �*�J— SEWER LINES ly u4AAI.}� DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION 61• AGRICULTURE WELL OTHER WELLjO--f— PITS/SUMPS "I— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial O Open Bottom 11 Manteca Dia. of Well Excavatio Dia. of Well Casing <br /> T%��Domestic/Private �7q�Gravel Pack ❑ Tracy Type of Casing_ / Specifications <br /> 1'I Public 1-I Other 71 Delta Depth of Grout Seal r Type Grou 1� <br /> 1 i v <br /> I I Inigation ,,�� — Approx. Depth 1 I Easter Surf cs Seal Installed Dy \ <br /> Repair Work Done Type of Pum �' -S�S. �f.P. y y Stale Work Oone <br /> Well Destruction Well Diameter Sealing Material 6 Depth <br /> Or <br /> Depth - �_ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is <br /> available within 200 feet.) \ <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: ----Water table depth _ <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS ILI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 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 411 for all required inspections. Complete drawing on reverse ide. 1 <br /> Signori V, , (lam----7hle: / ' ^C Date: 7 ✓ <br /> F R D ART ENT USE ONLY <br /> Application Acceptsby �-- Data /61 . IArea <br /> Pit or Grout Inspection by DateUrinal Inspection by UJ Date 7_Z— 9 2— <br /> Additional Comments: — / -7 / <br /> Applicant - Retutn all copies L San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY DATE PERMIT-NO. _ <br /> NFO_ 9 CASH <br /> • EH i'324 M1aEV.$/M51 . �-r� <br /> EH imps / <br /> 71.0 , 6n -- l3 ? - ­70nn <br />