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:.P Y APPLICATION SAN JOAQUIN COUNTY PUBLIC HETH ENVIRONMENTAL HEALTH DIVISIONRYICE9 445 N SAN JOAQUIN, PHONE (209)46$-3420 ' I P O BOX 2009, STOCKTON, CA 95201 V,�o �_o.ekL �`'p►'1 PERMIT EXPIRES I YEAR FROM DATE ISSUED(f,�� 1pi_ P►S i Application is hereby made to San Joe (Complete in Triplicate application Se made in c quin County for a permit to construct and/or install the work herein described, This J ompliance with Ban Joaquin County Ordinance No. !} I ottquin County Public Health Ser ces. 5 4 and 1$62 and the Rules and Regulations of Ban yJob Address `Q i City Lot Size/Acreage &�� Owner's Ne Address Phone k !' I TYPE OF WELL/PUMP: NEW WELL ❑ ��sn �Phone I WELL REPLACEMENT Cl PUMP INSTALLATION El DESTRUCTION Ll Out of Service well ❑' f DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OT aring well ❑ --�_ SEWER LINESDISP TION AGRICULTURE WELL ---- PROP. LINE INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL" P ONSTRUCTION SPECIFICATIONS Ll Industrial 0 Open Botto Manteca Dia. o avatian C] Domestic/Private avel Pack' Dia. of Well Casing ❑ Tracy Type of Casing UI Public I-) Other n Delta Specifications Depth of Grout Seal i I I Ir gation _.Appros, Depth I I Eastern of Grout Repair Work Done L7 T i F"Surface Seal Installed by Type of Pump H.P.,+" ^� �,� Well Destruction p Well Diameter Sealing Material.& Depth State Work Done i Depth .. Filler Material-b Depth G TYPE OF SEPTICWORK: NEW INSTALLATION I I REPAIR/ADDITION'l l� OESTRUCTfON I {fyo septic system permitted if public sewer is I ,^ Installation will serve: Residence '. Commercial or eeL l mavailable within 200 I� s^ I Number of living units; Nubeir of beanm _drs Oth _ Character of soil to a depth of 3 feet: t SEPTIC TANK. ❑ T � Water 'table depth ype/Mfg Cepacit ! PKG. TREATMENT PLT. 0 y------� No, Compartments Distance to nearest: WellMethod of Disposal — _ Foundation property Line. ! �" LEACHING LINE } ❑ No. & Length of lines FILTER BED -Total0 Distance tonearest: Well len th/size :» - �. 9 li Foun dation —�� Property Line SEEPAGE PITS It Depth it i SUMPS Size Number L7 Distance :nearest: Well� DISPOSAL PONDS ❑ Foundr� ation----�..� Property Line I hereby certify that I have prepared this applicatio and—and—that work wiil'be done in accordance wiih San Joaquin county ordinances, stats laws an rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the foNowin d` n the employ any person in such manner as to become subject to workman's compensation lawsoof California,"rmance Conrk for t actor srhiring orpermit sub contraccissued, in I shelf no x certifies the following: "I certify that in the performance of the worts for which this permit is issued, I shall employ tion laws of California." p g signature The applicant st call for al re 1 P Y Parsons subject to workman's compensa-- ins ctions. C mplete drawing a arae s' Sign Title: x ..i.�„_. Date: —FOR DEPARTMENT �� _�' _._,-••",,. USE ONLY r ��. .. ..�..,...,...�.., APPlicatfan Aaeepted bye"'_""'. int �" _ ":« '. _ _;'^• "�.,.1 ''._�/ ��,� r Pit or Grout Inspection by- DatarB8 Date Final Inspection pp P, by?� ^-'- - Additions! Comments: / +9 Date b_ EC�'s[.a•[.fr Applicant - Return all Co ies `too: 77.r �'�°�"' P � San Joaquin County Public Health Services, Environmental Health Permit/Services A 445 N San Joaquin,, P 0 Box 2009, Stkn, CA 95201 �/�y�� / FEE AMOUNT DUE t AMOUNT REMITTED Cr 0l��J92 INfO CK CASH RECEIVED BYDATE PERMIT'NO. `"�✓0!/i . EH 124(REV,i i x Sl U b6 ;1 —t ' EH t4.4�2a