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SAN Application is hereby. nade.to San J application is made in r:oWliance v Josquin`County Public Health Beryic Job Address F *3 1 RI&�I Owner's Name,,.. S 4 r �- AA Contractor tc_li/ GRJ__S PUMP: NEW PUMP INSTAL DISTANCE TO NEAREST: 'SEPTIC TANK FOUNDATION INTENDED USE TYPE OF WEL 0 Industrial, 0 Open Bottom �„k�prnatpic/Private - IW Gravel Pack I'I Public 1.1 Other I I If -XQa ApPlor. of Repair Work Done U Type of Pump _ Well Destruction iii Well Diameter _ •TYPE OF SEPTIC WORK; NEW INST Installation will serve: Residence Number of living units: Number Characmr of. sop to a depth of 3 test: _ SEPTIC TANK. ' ❑ Type/Mf9 _ PKG."TREATMENT OLT. O Distance to i APPLICATION FOR PEgUIT OAQUIN COUNTY. PUB14C HEALTH SERVICES SNV I RONNM TAL .EiEALTH AI V I 3I ON J. F, HAZELTON AVE., PHONE (209)468-3420 P 0 BOX 2009, STOC%TON.. CA 952.01 (Complete is Triplicate) uin County for a perolt.to construct and/or install the work herein described. This San Joaquin County Ordinance 110. 5449 and 1862 and the Bolter and Regulation* of lien City S toot 91ze/Acreage 2.. X'r1E Phone '934- 3-L,6. Address :a - i Address license No. Phone ELL O WELL REPLACEMENT DESTRUCTI toot Serylce Well O" ION JW $YSTEM REPAIR O OTHER O 1lonitoring�ell O SEWER LINES DISPOSAL FLD.� c PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS PROBLEM AREA CONSTRUCTION -`SPECIFICATIONS Q Manteca Ola. of Well Encavot�. _ Df f Well Casing_ O Tracy Type of Casing •.. _— Specifications P F1 Doha :Oiapih of:Grout Seal Y Type of Grout Q gft'/' T 1 I I Esatern suliace'Seal Installed by cue -rot /,a -, n tf�a H.P. Stole - Work Done ._ewl//� !4 Sealing Material a Depth Filler Material ION I I REPAIR/ADDITION I I, DESTRUCTION I I (No septic system permitted if public saJaer is,: available within 200 test.► mmercial _ Other bedrooms Water table depth Capacity *o_ Compartments Method of Disposal Well Foundation Property Line X ,Total length/sire Foundation Property Line LEACHING LINE 0 No. 6 Length lines , FILTER BED .O Distance to rest: Wdlt'. SEEPAGE PITH I I .Depth _ SUMPS CI Distance to DISPOSAL PONOS " ❑ I hereby certify that I he" prepared this a rules and regulations of the San Joaquin Home owner or licensed agent's signature employ any person in'sueh ntannarac-16 b candiM the following: "I certify that in the tion laws of California." The applicant must call for, all req red iru Signed Application Accepted by �" r Pit ortion by Addhbl O.C.mmenta: c �t AppliceAt - Return all copies k . Eh 13,2A 1111Y. w si 1 !N 14.29 Sivas"y` Number t: Well Four#t{at on Property Line +' S on and that the work will be done in eCcor.MAce.wilh San Joaquin county grdirtances, state laws, and athe following: "I certify that in the performance of the work.for which this Permit isA*ued. I shag not s4ibfect to Workman's compensation laws of California." Contractor's hiring or sub -contracting signature nanco •of the work for which this permit Ie issued, I shall smpioy persons subject to workman's componsa- ions. Complete drawing on. reverie side. Title: rt" Date: 16-9 r� ��II%%' FOR DEPARTMENT USE ONLY! Qa[e�' Area �� Dato• nary paetjprt! 40' Dt 06001 Countyr .ru is Health �� :0Vq � "r' ed ri7vn ce�i: icviroffiebiaS Health Fermi t/Bervicee,�- C. 8at:eltoe Ave., P_,Pi4eiaM 2009. Stockton, CA 95201 FSE E i., MouNT R .TTFo` + �, ATE P MIT P.. �- DR IN 0 :; * H ,�Y q - r r _TZ ITI-1 / T, X .74