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f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE ' (209)468--3420 SEPTIC <br /> . P O BOX 2009, STOCKTON, CA 95201 <br /> P'RMIT VV-DT <br /> RES 1 YEAR FROM DATE ISSUED <br /> (Complete ,ilt1 Triplicate) <br /> I Application is hereby Stade to San Joaquin County for a permit to construct and/or install the cork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> z_ _ City I6 rLot Size/Acreage 3 <br />' Jab Address <br /> y Phone <br /> Owner's Name . r'J J�{ 4. �� Address <br /> Contractor <br /> Address ,S�' License No. Phone <br /> l TYPE OF WELL/ NEW WELT ❑ WELL REPLACEftNT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SE TIC TANK !�` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FO NDATION 4 's 3 V+fISRICULTURE WELL OTHER WELL PI SI SUMPS <br /> INTENDED USE T PE OF WELL PROBLEM AR LU FECIFICA IONS <br /> Q Industrial Q pen Bottom ❑ Manteca Dia, <br /> Ex tion Dia- f Well Casing <br /> 4 Spec Ications GQ <br /> Ca DomesticlPrivate ❑ I�e� ck L] Tracy TVpgeo <br /> I <br /> I'1 Public f-1 their n Delta Depth of Grout Seal Type f Grout <br /> I i Irrigation Approx Depth l I Eastern uriae al Installed b <br /> Repair Work Done U -Ty of Pu p H.P. State Work Done <br /> Well Destruction ❑ <br /> De It Filler Material A Depth <br /> TYPE OF SEPTIC WORK: N W I STALLATION REPAIR/ADDITION i I ESTRUCTION INo septic system pe milted if public sewer is <br /> mailable within 204 f et.) <br /> Installation will serve: Resi a ce— Commercial Other <br /> - Number of living units: Number of bedrooms <br /> Character of soil to a depth t We h <br /> SEPTIC TANK. O 0ype/Mfg L Cd/1 C pacity__A/ve No. Compartments <br /> PKG, TREATMENT PLT. ❑ongo t Method of Disposal <br /> 'Distatme_to nearest; Well ��Z F Property Line <br /> f A N LINE No. Length of lines __ T tat length/size <br /> ` tQ f 1 Distance to nearest: Well Foundation Property Line �® - <br /> SEEPAGE PITS Depth Size�� umber 3 E <br /> SUMPS I Distance to nearest: Well ]v ,Foundation Property Line f 0 CJ <br /> DISPOSAL PO <br /> I hereby certify prepared this application and that the work will beIn , cc nce with San Joaquin county ordinances, state laws, and . <br /> rules and regulations of the San Joaquin County # s- <br /> Home owner o licensed agent's signature certifies the following y thapa <br /> er#o nce of the work for which this permit is issued, I shall not''.';, <br /> employ any rso t alifornia." Contractor's hiring or sub-contracting signature <br /> r certifies the f rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa t. <br /> tion laws of C I orn a. <br /> The applicant ust call for all=quiredinspe � S. Complete drawing on reverse side. <br /> Signed Title: _ Date: _ZZ <br /> PARTMENT USE ONLY Q <br /> Application Accepted by Date —�"� y�" Area r 2 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> f <br /> Additional Comments: k' <br /> Applicant - Return all copies to: an Joaqui Coun y Public HealthSer ices <br /> k Environmental Health Permit/Seiv <br /> 445 N San Joaquin, P O-Box 2000,6th CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATS PERMIT'NO. <br /> INFO _ <br /> . EH 13-24(REV.1/95Y <br /> EH 11-M <br /> f <br /> I. ; <br />