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SAN . ('aL Imo./♦fir is�lv.l _ v.• _ u.r.• � <br /> '`�QUIN COUNTY PUBLIC HEALTH SrRVICES <br /> -YV I RONYEtZTAL HEALTH D I V I S I, <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR---FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> �;;�Application in hereby sande to San Joaquin County for a permit to construct and/or install the work berein described. This <br /> arplication is made in conplisnee with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San <br /> Ocoquio County Publit Health fieryiees. <br /> Job AddressG /n-}'I G CnyS-6C'�+7)0 Lot Size/Acreage <br /> ' Owner's Name 611G4L1'-6'1 LrSA R,d,,..'> !a- Address 24 IQ Cc:—,1r Qf,it23,Qll r•r.crn- r'A-- Phone <br /> Contractor i I :1Address LrL r S �I License No. J�'✓'� <br /> `L t= Phone -moo'FSS'��/ <br /> TYPE OF WELL/PUMP: NtW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or service Weil ❑ <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX Monitoring Well o <br /> DISTANCE TO NEAREST: SEPTIC TANKS ICC' Ion r >l " 5o f `r +'tis 7� <br /> SEWER LINES > DISPOSAL FLD. t PROP. LINA <br /> FOUNDATION AGRICULTURE WELL �tOTHER WELLr PITSlSUMPS <br /> ' INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom D Mang Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Privets D Gravet Pack Tracy Type of Casing_ Specifications <br /> ' !'I Prrblic f l Other fl Dells Depth of Grout Seal �P/ Type of Grout "eraf'(,edrOK-f/Fr,n�r. <br /> I 1 Irrigation pprax. Depth 11 Eastern Surface Seal Installed by KU. rhrrilct <br /> Repair Work Done Type of Pump H.P, State Work Done _ <br /> Well 0estru n ❑ Well Diameter Sealing Material i Depth <br /> ' Depth 1riller Material t Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permi is server is <br /> available wit ' eat.! <br /> ins 10118lion will tern: Residence — Commerciwi Other <br /> faNumber of living units; Number of bedrooms <br /> Character of sol! to ■ depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/MI Capacity No. Compartments I <br /> ' PKG. TREATMENT PLT Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 LEACHING LINE 0 No. 5 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nacre un &Iron Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> ' SUMPS LI Dist&nu to nearest: Wet ropeny Lina <br /> D15P.f1SAL-.DA+aB <br /> I hereby csnify that I have prepared this sppfication and that the work will be done in accordance with San Joaquin county ordinances, state Laws, and <br /> ' rule{ and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which thio permit is issued, I shall not <br /> ampioy any person in such manner as to becoms subject tD 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 compentia- <br /> tion Laws of California,- <br /> The applica H Do for eN required ' do verse side. <br /> Signed / Title: Date: �7 <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> ' Application Accepted by IV 1} Date Ara& <br /> Ph or Grout inspection by Dote Final spection by Data <br /> kddlilonal Comments: <br /> Applicant - Return all copiee to: San Joaquin County Public Health Services <br /> Envirnnmental Nealth Permit/Services <br /> 445 N San Joaquin, P O Box 200A, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED sY DATE PERMIT-NO. <br /> INFO CASH <br /> r (� f/) [� <br /> K <br /> 3 24 rnty. war $``j c60 Jz ( ' +-�' l� 13 0505 <br /> �H re.ae -- <br />