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SAN .QUIN COUNTY PUBLIC REAL90 �61�— <br /> V r:NVIRONMENTAL EIEALTH DIV S�, <br /> 445 N SAN JOAQUIN , PHONE; (20 )46 42=q,51-tn <br /> P O BOX 2009 , STOC%TON, C II � <br /> L PERMIT EXPIRES 1 YEAR FROM D91TS1ED <br /> (Complete In Trlpllml \I 47107 <br /> �s Application Se hereby mmde,to San Joaqu In County for a permit to construct and/or linsta'll a s o an <br /> application Se made in compliance vlth San Joaquin County Ordinance No. 549 and-'i9�'"attQ' <br /> Joaquin County Public Health Services. e e e,3 7Yl7 <br /> i Lot Size/Acres a <br /> +7 E r it�r�r PAn — City <br /> 1110, Jab Address <br /> .� f �G7Y1r1 r� . <br /> t \'1 YlYl�L��� Phone <br /> Address "" " f <br /> Owner's Name lJ , <br /> ^ <br /> �- ` Phone 36 <br /> Address �cense No <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ <br /> OfWELL/PUMe: NEW WELL ❑ OTHER ❑ Monitoring Well �� <br /> TYPE <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> `saSEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS S <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Dia. of Well Excavation <br /> L, industrial ❑ Open Bottom C3 Manteca Specdlcations <br /> ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> I'I Public <br /> CI Domestic/Private Depth of Grout Seal Type of Grout <br /> 1-1 Other fl Delta <br /> I I Inigation _Appro*. Depth I I Eastern Surface Saul Installed Slate Work Done — <br /> H.P. <br /> Repair Work Done L3 TypeWall Destruction C1 Well <br /> of Pump Wall Diameter Sealing Material L Depth <br /> Filler Material L Depth <br /> ` Depth _----- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I DESTa�ailabPi <br /> within 200 feel lad d public sewer is <br /> RUCTION I I <br /> Installation will serve: Residence.,K_ Commercial_ Other <br /> r f bedrooms Number o �1_-- V� <br /> t. Number of living unite: � Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> r 1.� <br /> r PKG. TREATMENT PLT. ❑ r,�'t. Foundation.20 Propene Line r` <br /> Distance to nearest: Wall G <br /> M"yTotal length/size <br /> LEACHING LINE JV No. 6 Length of lines Property Line <br /> Foundation p y <br /> FILTER BED ❑ Distance to nearest: Well .` <br /> .C- umber <br /> SEEPAGE PITS Depth Size , ^ r / <br /> �l a�� Foundationl� Property Line <br /> — <br /> � SUMPS LI Distance to nearest: Well�. ar_ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wish San Joaquin county ordinances, state laws, an <br /> Vie rules and regulations of the San Joaquin County g <br /> Home owner or licensed agent's signature certifies the following 'I certify that in the performance of the work act which this permit ring or o issued. I signature <br /> shall not <br /> 5 of California." <br /> subject to workman's compensation law <br /> cemploy any person in such ert fisc the following! "I certify that m the perfornner as to emance of the wok for which this permit is issued, I shall employ peroso taisubject to woorkmanla sub-contracting <br /> sea tion laws of California." <br /> The applicant must call for all re i d inspe ions. Complete drawing on reverse side. �b —7 /y ? <br /> i'1i . . 0 .` _ Date: ` J <br /> _ Title: <br /> Signs 7y"�-� <br /> � FOR DEPARTMENT USE ONLY <br /> •a /v 7 t3 I <br /> Date Area <br /> Application Accepted by h / <br /> Final Inspection by <br /> star it r Grout Inspection by <br /> Additional Comments: <br /> Applicant - He turn all copies to: San EnvironmentaCounty <br /> l Health permiblic lt/Servicesealth vl cos <br /> 445 N San Joaquin, p 0 Box 2009, Stkn, CA 95201 <br /> �--- FEC EIVEO BY GATE PERAIJ NO. <br /> ,u AMICUNT REMITT is q <br />