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Ak'i',Lrll:A1l.Un .firvu raa•�.. <br /> i <br /> SAN ­`AQU,IN COUNTY PUBLIC HEALTH VRVICES I <br /> (% VI= ON11t <br /> RENTAL HEALTH D I V I S <br /> 445 .N' SAN"' JOAQUIN, " PHONE (209)468' 3420 <br /> P O BO%= 2009, STOlf, CA 95201 <br /> PERiItIT EXPIRTS ] YE 1FR !I! D T 311F�U <br /> (CO, mpi-ete in ;Triplicate) <br /> Application is hereby toads to Sas Joaquin County for a pertsit to construct and/or install the work herein described. This <br /> application ie made in cotWiiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �vyy7"T C) City fCot Size/Acreage <br /> Job Address <br /> ++ 11 I <br /> C GV:`bre �'� Rr,y�tticlf'SCQ. Address 7J4 O( rn~ rt �+ ' a Phone I <br /> Owner's Name 1 r <br /> Contratior II 1 <br /> ' AddressA f0 Lct r # License I �" . W - Phone <br /> TYPE OF WELLlPUMP: W WELL ❑'" WELL REPLACEMENT Cl DESTRUCTION Cl put of Service Well Gl <br /> OTHERX Monitoring Well C7" <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C7 5a Ill <br /> tort SEWER LINES yto° ) DISPOSAL PLDy1C�. PROP. LINE j <br /> DISTANCE 70 NEAREST: SEPTIC TANK PITS/SUMPS I <br /> FOUNDATION AGRICULTURE WELL:`I_ OTHER WELL— <br /> INTENDED USE TYPE;OF WELL PROBLEM AR ONSTRUCTION SPECIfICATIONS " Dia. of Well Casing <br /> C1 Industrial ❑ Open Bottom" �"i <br /> at e- Dia..of Welt Excavation v <br /> T of Casing— <br /> (1 <br /> Specifications <br /> (1 Domestic/Private 0 Gravel Packcy yPe., 9 -��/ Type of Grout '�- <br /> I'1 Public Cl Other elts Depth of Grout Seal <br /> i I Irrigation pprox. Depth I I Eastern" Surface Soul Installed by 1 <br /> 'H.P, ..N State Work Done <br /> Repair Work Dona Type of Pump : <br /> Well Dest n 11 Well"Diameter <br /> Sealing Material i Depth <br /> Depth Filler Material`) Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I'' REPAIRIADDITION Y I DESTRUCTION I I IfJo septic system permit rc sewer is <br /> ovailsbli wit <br /> Installation will serve: Residence— Commercial ' Other <br /> Number of living units: "Number of bedrooms <br /> Character of III to a depth of 3 feet: Water labia depth <br /> SEPTIC TANK- ❑ TypCapacity No. Compartments <br /> ilMf <br /> PMethod of Disposal <br /> KG. TREATMENT PLT j <br /> Distance to nearest: i 'Well foundation Property Lina <br /> - <br /> LEACHING LINE Ll No.r Total lengtWsize 6 Length of lines - <br /> FILTER BED n Dimance to un a lon Property Line <br /> SEEPAGE PITS 11 Depth Silo Number <br /> SUMPS Ll Distance to nearest: Wel rope rty Lina <br /> the work wil <br /> d,that l be done in accordance with'San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application an } <br /> rules and regulations of the San Joaquin Countyr <br /> Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shell not JI <br /> employ any person in such manner as to become subject:to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance off the work for which this permit is issued,I shall employ persons subject to workman's compenaa" <br /> tion laws of California." <br /> The applies at for al!"required ' alio worse side. <br /> Signed Title: v / _ Date: 7 <br /> OZ <br /> -7 II <br /> FOR DEPARTMENT USE ONLY I <br /> ApplicationAceeptad by ► '' Date Area <br /> C0 gr <br /> Ph or Grout Impaction by Date - Final spection by Dets <br /> mss. 1 <br /> Additional Comments: , <br /> Applicant - Return all copies to: Sin Joaquin county Public Health Services <br /> Enviionmerital Health permit/Services <br /> 445 N San Josquill O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT LtdE AMOUNT'REMITTED CRECEIVED BY DATE PERMIT Nt}. <br /> CASH 9 <br /> INFO EH t3"MI11EV.r1 5Ilq�/ ✓ <br /> EH 1.•30 <br /> i <br />