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MME <br /> 0 <br /> 445 N SAY JOAQUIN, PHONE (209)468-3490 ��rrlL9it5 <br /> SC7// '�/1J° S P 0 B• 2009, STOCKTON, CA 95201 _ Q <br /> _ PERMIT EXPIRES 1 YEAR FROM DATE ISSIIID <br /> (Complete in Triplicate) <br />'!cation is hereby trade to San Joaquin County for a permit to construct and/'or install the work herein described. .This__:. <br />.lcation is s de in compliance vith San Joatuin County Ordinance No. 549 and 1862 and the Rules a^d Regulations of San ; <br /> uta <br /> County Public Health Services- <br /> address <br /> address `r`P 35 r � t/ At't r City S5 cD6'"/"r ! Lot Size/Acreage - <br /> ar's Name Chty�� Address PD h3 ox,5v,9y _s,,-� , ,/-513 Phone g7Z <br /> A�f n � e577 <br /> TJV i� <br />:actor I`� �I�//1 Address r � ZZ-,:3/ License No. (07�n Phone g5Z—955g <br /> OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �tl &VInIOTHER, _ _ Monitoring Nell ❑ <br /> ANCE TO NEARES ' SEPTIC TANK SEWER LINES 115t_ -7";' - DISPOSAL FLO. PROP. LINE <br /> OUNOATION AGRICULTURE W LL 7' OTHER WELL714�1/ PITS/SUMPS _ <br /> iTENDED USE TYPE OF WELL PHOS LEM AREA CONSTRUCTION SPECIFICATIO�h <br /> Justrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing <br />�mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br />:blit (l Other n Delta Depth of Grout Seal Type of Grout <br /> iclation _Approx. Depth I I Eastern Surface Saul Installed by <br /> r Work Done 0 Type of Pump H.P. State Work Done _ <br /> Destruction ❑ Well Diameter Sealing Material t Depth <br /> Depth Filer Material L Depth <br /> OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system permitted if public sower is <br /> available within 200 fear.) <br />:allarion will serve: Residence _ Commercial_ Other <br /> tuber of living units: Number of bedrooms <br /> aracter of sail to a depth of 3 feet: Water table depth <br /> IC TANK ❑ Type/Mfg Capacity No. Compartments <br /> TREATMENT PLT. ❑ Method of Disposal <br /> Oistanca to nearest: Well Foundation Property Line <br /> RING LINE 0 No. 6 Length of lines Total length/size <br /> R BED ❑ Distance to nearest: Well Foundation Property Line <br /> AGE PITS I 1 Depth Size Number <br />�S LI Disrance to nearest: Well Foundation Property Line <br />)SAL PONDS ❑ <br />';y 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 /> end regulations of the Sarr Joaquin County- <br /> owner <br /> ountyowner or licensed agent's signature certifies the following- "I certify that in the performance of the work for which this permit is issued. I shall nor <br />.y any person in such manner as to become subjecr to workman's compensation laws of California." Contractor's hiring or sub-contracting signature" <br /> es the following: "L certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> ws of California_" <br />:)plicaI'Mi.11lor all required inspections. Complete drawing on rev se side. - <br /> Title: Date: <br /> c YU <br /> ( � / 4pl. �FOPARTMENT USE ONLY <br /> arion Accepted by' r�'r' S J / <br /> Data Area`' <br /> Grout Inspection Dy Date Final Inspection by ^Date <br />)nal Comments: <br />?plicant — Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health, Permlt/Services <br /> 445 N San Joaquin, P 0 Boz 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 2 RECEIVED BY DATE I PERMIT NO. <br /> INFO ��Jj CASH /y <br /> 9 - Cc I 00"ti � Al�� -zZ W <br />