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t <br /> ' SAN *UIN COUNTY PUBLIC HEALTHV ICES <br /> DI <br /> ENVIRONMENTAL HEALTH M S I .f <br /> 445 N SAN JOAQUIN , PHONE (209)468-3420 <br /> ' P 0 BOX 2009, STOC%TON, CA 95201 <br /> PERMIT MIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ' Application 1a hereby made,to Baa Josquin County for a permit to construct and/or install the Work herein described. This <br /> application Se made in coarliance vith Ban Joaquin County Ordinance no. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Be"tee•, ,,(( <br /> ' JpZ�O �a� City �O LoC Site/Acreage <br /> Job Address ��"' 1'11 <br /> / �ar�ils <br /> 1004/ OvPr�fe'aa� hard' Address L" C E03f1 leoi�LogePhone. 233 66/ <br /> owns. Nome' ,/Contractor RSk f/rs1OCi4 Ytl Address-&g/ License NoL47-q9�y/� Phont�/ VL aDa <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT II DESTRUCTION Out of Service Well 0 <br /> Wellitoring <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Mon � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1l Industrial 0 Open Bottom 0 Manteca Die. of Wei Excavation Dia. of Wen Casing <br /> Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications- <br /> I'll <br /> pecifications I'1 Pubile 171 Other n Delta Depth of Grout Seal Type of Grout <br /> ' 1 I Inigstbn _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. Stats Work Done _ <br /> Wen Destruction Wen Diameter SGB Sealing Material a Depth <br /> ' Depth ffJerk X4,0 Filler Material a Depth , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted If public aswer if t <br /> available within 200 feet.) <br /> Innanstion will carve: Residence _ Commercial_ Other t <br /> ' Number of living units: _ Number of bedrooms <br /> Character of sera to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfo Capacity No. ComparIMAnti r <br /> ' <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> r' /! ' f, - C" <br /> Distance to nearest: Wen Foundation PropeffA)6,?S�_ <br /> R!CGErtse <br /> .ir <br /> LEACHING LINE 0 No. g Length of nnaa Total longi i. <br /> ' FILTER BED n Distance to nearest: Wen Foundation Pr r rty L • fes"` T I <br /> SAN J NJ ' <br /> LIC HEALTH `Fc <br /> SEEPAGE PITS 11 Depth Sire L1 h u f <br /> ' SUMPS LI Dlsana to nearest: Wall Foundation rap• ti <br /> DISPOSAL PONDS O <br /> work will be dons in accordance with San Joaquin county ordinances, state lava, and <br /> I hereby comity urst I have OreParod this application and that the <br /> Nits and regulations of the Son Joaquin County <br /> ' Home owner or liconsed agent's fignsturs cemilies the following: "I certify that In the performance of the work lot which this permit is Issued, I Shan not <br /> employ any person In such manner as to become subject to workman's compensation laws of California." Contesctoi s hiring or sub-contracting signature <br /> aanifles the following: "I conlfy that in site performsnee of the work for which this permit Is Issued, I shall employ persons subject to workman's componss. <br /> Ito" lows of California." <br /> ' The applicant t aR for 1A Hent. Complete drawing on reverse side. /�r <br /> Sq <br /> Title!"/��rK�•' L�IfNMNswaf►t .�+ViaUDete: _S 9 Z <br /> FOR DEPARTMENT USE ONLY <br /> ' AppHcstbn Accept q Date" Area <br /> PX a Grout InapeNbn by Gat r-T--rfJ % Float Inspection by Dees 3 <br /> ' AddhIonel Comments: <br /> Applicant - Return all Copies to: San Joaquin County Public Health Services <br /> inviroomental Health Permit/Serricea <br /> ' 445 R San Joaquin, P 0 Box 2009, Stkn, OA 93201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH ECEIVED gY DATE PERMIT'N0. <br /> CK <br /> INFO /� D T PERMIT <br /> NO <br /> Ft1 U.74 laity.11.01 <br /> D /i-/ir � (/V <br /> ' EN 11,30 Lel <br />