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SAI OAQUIN COUNTY PUBLIC HE TI EEVICES <br /> EN'VIRONh=TAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PETIT Z2MIR, S 1 YEAR ,EROM DATE ISSUED <br /> (Complete in Triplicate) <br /> leAppl eistion is hereby bade to San Joaquin County for a peralt to construct and/or install the work herein described This <br /> application it made in eouplia.nee with awn Joaquin County Ordirwnce No 5h9 and 1662 and the Rules gad Regulations of San <br /> Joaquin Countr Public Eealth Berrices. <br /> .lob Address Sy3 rQ I; 1-1;1-41rt.G 0'P&aQ( City BdPt Lot Site/Acreage AIA <br /> Owner a'Namer�h Address ISD r�MJ,i4d>�I*� �'dt Beirt0 Phone /D$�Z SOC <br /> Contract /araAeir,�lyite--r Address Po 96,e r A-SGtef, 64�. 07 ICV nse t+lo e17-5 pG Phone 71P7744tf ?&W <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION D Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D Monitoring Well <br /> DISTANCE 70 NEAREST SEPTIC TANK ►JA SEWER LINES -WA <br /> DISPOSAL FLD -Nk PROP LINE <br /> FOUNDATION ^. 25rk AGRICULTURE WELL -U-A-- OTHER WELLt—�d—P4ef PITS/SUMPS _1L <br /> INTENDED USE t{1 TYPE OF WELL PRDBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ induatrra—� 0 Open Bonorn D Manteca Dia of Well Excavation Out of Well Casing 2"' <br /> Ci Domestic/Private ❑ Gravel Psck ❑ Tracy Type of Casing PVG yd -- Specrttcatrons ! <br /> I I Pubiic rn � <br /> k_bihar f�jari,�) n Delta Depth of Grout Seal 5s. - Type of <br /> I I lrtvjatron !�Approa Depth I I Eastern Sur4aea Seal Installed by Ca-,4-A cid wcel-r f Lt>- <br /> Repair Work Dore U Type of Pump H P _ teff. State Wok Done ...-„ N Xr — <br /> Wall Destruction O Well Diameter Scaling Material i Depth <br /> Depth Filler Material i Depth 3 Ser i - �- IS—;-/ <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public wwaf is <br /> available within 200 lest I <br /> Installation will serve Rssedence_ Comntercof_____ Other <br /> Number of frump units Number of bedrooms <br /> Am Character of loll to a depth of 3 feet Water table depth <br /> MOMDTIC TANK D Type/M19 Capacity No Compartments <br /> PKG TREATMENT PLT O Method of Disposal <br /> Distance to nearest Weil Foundation Property Line <br /> LEACHING LINE Cl No i Length of lines Total length/sue <br /> FILTER BED ❑ Drstancs to nearest Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Dtstance to nearest Wall Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances state laws and <br /> rules snd regoutrons of the San Joaquin Cauaty <br /> Home owtar or licensad apani s sgnature condw►s the following I eartity that in the performance of the work for which this permit is issued 1 shall not <br /> employ any person in such manner as to became subject to workman s compensation taws of California Contractor s hiring or suDconira cling argruture <br /> unifies.the following I certify that in tete performance of the work for which this permit is issued I shall ornpioy persons subject to workman s eompenss <br /> non laws of Calrfornla w <br /> The applicant must call for an requited rnspectwns Complete drawing on reverse side <br /> Sqn+ed Titie Date <br /> FOR DEPARTMENT USE ONLY <br /> Apolication Accepted by Date Ara• <br /> Psi or Grout Inap►ction by Date Final Inspection by Date <br /> Addnional Comn-*r%u <br /> Applicant - Return a13 copies to San Joapuic County Public Health Ser%lces <br /> EDclroamental Healtb Percit/Services <br /> 445 N San Jonqu1n. P 0 Sox 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMDUN7 DUE AMOUNT REMiTTED C K S RECEIVED ISr DATE PERMIT NO <br /> tw Madl IACV ii-ai <br /> EH is 39 <br />