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/91;0 <br />2 3 deda,z . <br />o.r <br />NEW INSTALLATION IP REPAIR/ADO(TION TYPE OF SEPTIC WORK: DESTRUCTION I <br />Capici <br />Water table math <br />No. Compartments <br />SEEPAGE PITS <br />SUMPS <br /> <br />(.1 Distance to nearest: Well <br />DISPOSAL PONDS 0 <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cc unty ordinances, stele laws, and <br />rules and regulations of the San Joaquin County <br />Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for whidh this permit is issued. I shall not <br />employ any person in such manner as to become subsect to workman's compensation taws of California." Contractor's kering or sub-contracting signature <br />certifies the following: "1 certify that in the performance of the work for which this permit is iseued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />No. & Length of lines <br />Distance to nearest: <br />LEACHING LINE <br />FILTER BED <br />Size I I Depth <br />) -3420 <br />AlOttt A C <br />ff8-4PLED <br />cl/INiVslil 1 t.be lgAn <br />License No. 9153 f1phor,3317-C9 2 2, <br />DESTRUCTION Cl Cut of Service Well 0 <br />OTHER G <br />Monitoring Well 0 <br />SAL FLD PROP. LINE — <br />OTHER WELL P1TS/SUMPS <br />Dl <br />Method <br />Property Line <br />ounoation <br />The The applicant mu callclot el red ins one- Complete drawing on reverse side. <br />Title: i'—i--ZiCVIL?t <br />INTENDED USE <br />Cl Industrial <br />1.1 Domestic/ Private <br />I . Public <br />I Irrioalion <br />Repair Work Done <br />Well Destruction <br />SEPTIC TANK 10 <br />Installation will serve: Residence ri.. Commercial 'ther <br />Number of living units: Number of bedrooms <br />Character of sail to a depth of 3 feet; <br />Type/Mfg <br />TYPE OF WELL <br />Open Bottom <br />Gravel Pack <br />LI Other <br />Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />PROBLEM AREA CONSTR ' le SPECIFICATIONS <br />Manteca Dia. eli E cav860n <br />Tracy pa of Cast <br />Cl Delia Depth of Or <br />l I Eastern Surface Se <br />H.P. <br />Sealing Material & Depth <br />Fill/sr Material 'IV Depth <br />Die 'of Well Casing <br />Specifications <br />ut Seal Tyco of Grout <br />Installed by <br />State Work Done <br />To ngth/sire 121 <br />Propert Line <br />ur <br />oundarion PtoPertV Line go '-/Y ' a <br />'TY <br />„LI <br />Date/ <br />2- o1,3 Area <br />ir 1 I 1811,11%!-- Data '1-43 )/3 <br />Final Inspection by Date <br />San Joaquin County Public Uealth Service - <br />Environmental Health Permit/Services <br />445 N San Joaquin, P 0 Box 2009, Stkn, <br />Applicant - Return all copies to: <br />95201 069 ., <br />FEE <br />INFO <br />9\-I <br />AMOUNT DUE AMOUNT REMiTTE0 CI RECEIVED BY CASH <br />DATE <br />// 4-. a _ / 1 it 1 a 6,05•57. /3 _ 9/24.) 1 93-//) EH 13.24 (REV. Si <br />Sri 1445 <br />Address Owner's Name <br />Contractor <br />TYPE OF WELL/PUMP: <br />DISTANCE TO NEAREST <br />r7Orir'' <br />WELL FiEPLACEMET <br />SYSTEM REPA <br />SEWER LINES <br />AGRICULTURE WELL <br />dress <br />NEW VJLL <br />PUMP INSTALLATION G <br />SEPTIC TANK <br />FOUNDATION <br />PKG. TREATMENT PLT, <br />Distance to nearest <br />ate: <br />FOR DEPARTMENT USE ONLY <br />2 <br />Signed x <br />Application Accepted by <br />Pit or Grout inievaction by <br />Additional Comments: <br />Lot Si ze/Acr cage <br />Application is <br />application is <br />Joaquin County <br />Job Address 2 / 6 00 /11 <br />It‘la septic system permitted il public 543witi is <br />available within 20C feet.) <br />C it <br />SAN JOAQUIN COUNTY PUBLIC <br />ENVIRONMENTAL HEALTH DI <br />445 N SAN JOAQUIN, PHONE (2 <br />P 0 BOX 2009, STOCKTON, <br />PERMIT EXPIRES 1 YEAR FROM <br />(Complwce in Triplic <br />rmit to construct a <br />made in compliance illth San Joaquin County Ordinance No. 54 9 <br />Public Health Services. <br />hereby made :to San Joaquin County ror a pe