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L C2 <br /> SAN JOAQUIN COUNTY PU3LIC HEALTH SERVICES <br /> �(I,r ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> t <br /> tPu` j P 0 SOX 2009, STOCKTON, C9 95201 <br /> PERMIT oEROM DATILISSUM <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joequln County for a Pere t to tcnetruet end/or install the work herein described This <br /> npplicatlon Is smile In CoWllance with San Joaquln County Ord nan^e No 5L4 and 1862 and the Rules and Regulations of sen <br /> Joaquln County Public Health Sorvices l + <br /> f <br /> Job Address r' � C� _���t S1zelAcrcega <br /> / - �/J J 5 -l' <br /> Owner s Name t r Ad..reaf - <br /> Phone <br /> �' <br /> �YPE OF WELL/PUMP NEW WELL .YELL REPLACEMENT DESTRUCTION 0 Out of derwice Well - <br /> PUMP INSTALLATI M SYSTEM REPAIR El OTHER 0 <br /> 14onitorind Vell C7 <br /> DISTANCE TO NEAREST ��y <br /> SEPTIC TANK C SEWER LINES __LZ_`_.^°AI�— DISPOSAL FLD PROP LINE L <br /> FOUNDATION - AGRICULTURE WELL Y—i OTHER WELL�_�C �- PITS/SUMPS <br /> INTENDED USE TYPE GF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> f]Industrial E7 Open Bottom 0 Maniere Dia of Well EYeawtq _iF11 0.8 of Well Casing <br /> oomaafic/PresaleGravel Pack C7 Traci Type of C+sfnq.,_ _ /—TV <br /> SpecdKanrns '� <br /> I ! Publk 1'1 Other f-1 Delia Depth o1 Grout Seal f Typa Grou f ' <br /> I I Ifrfgatnn Appro■ Depth I I Easter Surf a Seal lnstallad by 4ul <br /> Ropan Work Done Type of Pumn S�11>/J2t'�. P / z- Sfaie Wort Done r !, <br /> Sealing terial A Depth <br /> Well D/aWCIAn Welt Diameter , <br /> Depth ;2b j Tiller Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I i REPAIR/ACDITION I i DESTRUC rION ' I IND sap+.system perm lied d r rblfC sewer is <br /> avaftabsc within 2CG feat I <br /> tnstuflaton will serve Rewden•s, Commercial— Other t Y <br /> Number of k"unite Number of bedrooms <br /> Character of soa to a depth of 3 feet _Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capaclty No Compartments <br /> PI G TREATMENT PLT Cl Method of Disposal <br /> Distance to noaresl Well Foundaiion Propery Line {� �t <br /> r I <br /> LEACHING LINE 0 No E Length of lines Total length site f <br /> F LTER BED 0 Distance it)nearest Weil Fo,.ndatfon Property Lona <br /> I, <br /> SEEPAGE PITS 11 Depth Sue Number r I <br /> SUMPS LI Distance to newest Wea Foundivcti Property Lina it <br /> DISPOSAL PONDS 0 `� 1 <br /> I hsoeby certify ttisi I have prepared Ihh application and Ihm the work will tie done in accofdance with San Joacufn CL`unty ordinances state laws and ,y <br /> rules and regulation of the Sah Joaquin Couity <br /> 11o"owner or licensed agent a"nature Dandies eta roliow�nq 1 cezdy that In the performance of the work fu whKh this perms is issued i shill not i <br /> employ any person In such manner as to become subtest Ie worki^%n a comptlhsahon taws of California COnlrst tot it hurig or sul>COniriFUne signature i <br /> nertdiea Lha followt V I certify that,n the performance o1 the work for wf-ch this;wrrat is iasued I ahail employ gdrsons sv elect to worLman a CompensJ <br /> hon lags of Caloforhls I� <br /> The applicant MUIJAV for all requir d tnspectwne Complete dowing on feve1jI� rda t� <br /> Signed Data ' <br /> r� r t <br /> "�, F fi D ART ENT USE ONLY <br /> b <br /> Applisa' �t lceeplaa by ��, � �-� Date ' Area_ 3 <br /> Pit w Grout Intwillim by Gate /�rnsl Irspection by Data <br /> Addnlozal Cor� a 71,rrosntr, <br /> Applicant - heturn all copies t Lar Joaquin CCunti Public Health Servide �+ <br /> Environmental Hsal•h permit/Servlrea <br /> 445 N San Jozg,rin P p 13ox 2009, Stkn „A 9n2U1 <br /> HMG AM_OU <br /> NT DUE AMOUNT REMITTED ELEIvtO By DAT[ PEAMIT NO <br /> tr ti 7srsry rr.ai ecy/ r-" <br /> ,�t,m 010 < X°' l3a <br />