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APPLICATION FOR PERMIT 10 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> Apglicar.lan is hereby safe to SAn Joaquin County for a persalt to construct sod/er lnstall the vOTIt herein doserlirad. This <br /> %ppllcstion Is nada in eaailillancs with San Joaquin County OTdlnanCe No. 549 and '$Q asd that holes WA Regulations or Ban <br /> :twquin Cawty Public Health Services. r <br /> I o R W city��1'1Z Kn N Lot ai"�Acra"o <br /> Job Address } <br /> a <br /> Qwnrlr'a Nerve r Address <br /> ,--r0� <br /> Conitaetoe �+�Li►tt7�IF Address O P t k$ Nit ticensr No.G4 3 4 3Pnor+at <br /> LJ <br /> TYPE OF WELOPLIMP T NEW WELL Q WELL REPLACEMENT 0DESTRUCTION E]Out o[ Beorlce all <br /> OTHER d Monttrirtg 11.11 Lf <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C1 <br /> DtSTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES — DISPOSAL FLD. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL R W <br /> OTHEELL ►tTSlSUMPS .^ a <br /> as S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � } <br /> �-- i <br /> industrial C3 Open Bottom ❑Manteca Dia, of Well Esuvstwn C Dia.of Wen Cs$ftg <br /> U Onmest,ClPnvne C1 Gravel Pact 1.3 Tracy Type of Casing <br /> PieblfC <br /> I'1 Other O Delta Depth of Grout Seat — Type W Gmu <br /> �j Imijimron —Approx. Depth 0 Eesurfi Surleta Sat it Installed by <br /> Plash Work Done L] Type of Pump H.P. - Slate Work Done_ D <br /> Wall Destruction ❑ Well Diernetsr Sealing Dhtarlal i Depth <br /> H31e <br /> _ r IMtertal III Depth <br /> Depth 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION❑ DESTRUCTION CJ evo�t�t�� I1ed'f „"«w <br /> InRullaiii"will"I": Residence_ CornmerCial_ Other <br /> Number of living units:_ Number of bedrooms <br /> No.COR%WtRWM <br /> depth or 7 tool:to a d <br /> at soa: <br /> er il epWater Calais depth <br /> Charact . <br /> SEPTIC TANK Typet ol: Capacity----•—•- <br /> Mirred of disposM <br /> PKG. TREATMENT PLT.0 <br /> •� I <br /> Distance to nearest; wen Foundation PfePeM L'ne <br /> LEACHING LINE 0 No, Or Length of lines Total tengthlsiae <br /> i <br /> FILTER BED n Distance to nearest: WNProperty Lina <br /> E Foundation„ 1 <br /> 5 <br /> SEEPAGE PITS I I Depth —Sj:e Number <br /> SUMPS LI Distance to nearpC WNI Foundation <br /> Property Line F <br /> DISPOSAL PONOS Cl <br /> "eeby 01111 That I haw*prepar9d tris spphtaucin and that the work wdt be done in aCCOrdanee with San JosQu1n County Ordrnan0ea,state terse,acrd <br /> ru4s and r■oulahons of the San Josauin County <br /> Home owner of licensed agent`s signetuse conks,the IOtbmnq. "I CertitV that in the performance of IN work for whkh this Aatrmis is issued,1 tMNtno+ <br /> .—ploy any person in such manner as to beCAme subject ID warkman'a COmpenaat+pn live Of California.,,Canttattofa fnrrr'+g or tat ,eornpensa- <br /> „-t�'�ef the following:'•I comity that m the performance of the work for which this permit is iesued.I shall empty perso"tubleC <br /> •nn laws of Calllornlo", <br /> Tti• ■ever. tI Its I t atl 4 Fed inspett+ ns. Complete drawing verse uds. <br /> '.,pnfld .r�Lc[\\!!` c Title• Date: <br /> v FORD M ONLY <br /> Dau 33 <br /> �, anon Accepted by I Dart," ! Dau Final Inspection by <br /> I ..r Grout Inspect-on by ,� <br /> ISA <br /> onal Commor+ts <br /> aca4t — Reqs* all copies to: SAN JOAQUIN COUNTY P BLIC 11RALTH SERVICES <br /> LNVISONiIENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 4e5 N SAN JOAQUIN. P 0 BOX 70091 OTUCIITON, CA 06201 <br /> rtf a NECEIVED By DATE iERMrT N0. <br /> NFO )0 <br /> /��'0'J`+' ^ur AMt�VH1 nEM+TTtO CAST <br />