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3 — c2A,5—D <br /> SAN '.QUIN COUNTY PUBLIC HEAL �6 <br /> ENVIRONMENTAL HEALTH DIVt 20 <br /> 445PN0X <br /> SBOJOAQUIN, PHONE (20 <br /> 2009, STOCKTON, CF <br /> PERMIT EXPIRES 1 YEAR FROM DAfT �—ED <br /> -71 1-7 <br /> (Complete in Trlpllcat ) 4�(D <br /> 011. This <br /> Application is hereby made,Lo San Joaquin County for a permit to construct �(or Sneta a an <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and-Y86'P' <br /> Joaquin County public Health Services. I /Trr,��' <br /> E _�1�.7� bJ J 1f ,� Lot SSxe/Acreage 53 <br /> '27SC /j'r /\ City � L1U�l-L-- <br /> Job Address <br /> !<J././� nDrlyl�.{i R-- Address �`✓r ' '"'�L '< - Phone <br /> Ownei s Name �to* <br /> C, Phone <br /> Contractors Address <br /> d��l / J <br /> icense No <br /> of service well D <br /> TYPE OF�P' NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ OutMonitoringWell ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR OTHER O <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK W <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> Qs <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSDia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> 1 <br /> Type of Casing_ <br /> (-I Domestic/Private 11Gravel Pack C3 Tracy Depth of Grout Seal Type of Grout <br /> fl Other P Delta <br /> I'1 Public (� <br /> I 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> of Pum H,P. State Work Done— <br /> Repair Work Done L3 Type p Sealing Material a Depth <br /> Well Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.`1` REPAIR/ADDITION IF I I availableseptic <br /> le w thin 200 fee[.�ed it public sower is <br /> Installation will serve: Residence )< Commercial +� <br /> Other <br /> Number of living units: .— Number of bedrooms ,-1_— Water table depth <br /> Character of soN to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK O Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line2$�— <br /> Distance to nearest: Well <br /> _ Total length/size <br /> LEACHING LINE W No. b Length of lines <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line v <br /> Size - / f7 c Number <br /> SEEPAGE PITS Qf Depth , ^ r / <br /> SUMPS LI Distance to nearest: Well —� <br /> Foundation Property Line lr:ba. — <br /> DISPOSAL PONDS ❑ <br /> 1 hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub <br /> -c°^trading signature <br /> certifies the following "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for all zed ins on reverse side. >b f 3 <br /> i'v_ . pDate: JSign ho <br /> RTMENT USE ONLY Date /,PArea <br /> Application Accepted by �Final Inspection bV ateit r Grout Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: Ravi roament loNealthSan Joaquiupermit/Servicesblic Health vlces <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> RECEIVED BY DATE PERMIT NO, <br /> L.f QEEAMOUNT DUE AMOUNT REMITTED <br /> �� <br /> . ER,a.z.laEv.rr•si :I <br /> . ov , o� 1lDsi '73 5V (�,-- le 7 3 <br /> r4 'C" <br />