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SAN JOAQUIN COUNTY PUI31.1C UEALTli :;EItVICE;;
<br /> ENVIROMMENT.L 11EALTU DIVISION
<br /> 1601 E. UAZELTON AVE. . PHILINL C''09)468-:141U
<br /> P U 11UY 2OU9, S'1'OCKTUN, CA 952U1
<br /> PEIiLIT liXPIlt1iS i XEAt�fjUL1 1)n1'1: I��U1;1)
<br /> (Complute in '1'ripl.lCL te)
<br /> Application is hereby wade to San Joaquin County for a permit tv c�:.,,tract and/or install u.. .
<br /> application is wade in cosigilleace with San Joaquin County Ordinance 11,. ;vy and 1802 and ti,e I...
<br /> Joaquin County PPublii/c Health Service
<br /> Jub AOdreN 924� ��� //�i�/�L /t�S�.CLS.L--- --. l..ry
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<br /> Owner's Narner 1G:Sr .�. G'/TC'.vC1Add,uss ��L��-��_• ����w t: ;/
<br /> }t COnllaeta ,_r1Jt1,7L License No.
<br /> TYPE OF WELL/PUMP NEW WELL r; WELL HEI LACE+.1lNf UESTHuCt1,,
<br /> PUMP INSTAL O SYtiTEM HEPAIN plr
<br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES . .-_ UISVU;,AL FLO
<br /> FOUNDATION AGR URE WELL OTHE
<br /> iNTFNDED USE TYPE OF WELL PROBLEM AREA CO UC,jPECIFICATIONS
<br /> El Industrrsd U Open Bottom n Manteca Wel vatron
<br /> E I Domestic/Pnvata Cl G7 of Pack ;"] Trac Type of Ca►,nU _
<br /> i'1 Public 1'l Other it' Dena Depth of(,rout Seal ___�— I',.• _..
<br /> r I fnrudtron __A o>r Dlspth 1 1 Eastern SuAacu Sv,d Initaned
<br /> Repair Work Done De of Pump H P _ Suq Work Done
<br /> Wall Destruction D Wen Diameter Sealing Material A Depth 11\
<br /> - -
<br /> Depth _ /lller Material Depth
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i GLSIHUCIION 1 I INo septic sy,o..,, , ,y
<br /> &0 rr E NOME available with- C
<br /> Inatalla,,on win serve: Residence_ Comme•cwl-_ Other
<br /> (\
<br /> Number of hiring units: Number of bedrooms.� •�.
<br /> Charealar of sal to a depth of 9 feee -Water
<br /> SEPTIC TANK Type/Mfg _- P•! A__Cap ruty_L,r ar �/ No Cum,,,,,,. _ -
<br /> PKG. TREATMENT PLT.Q Atelhud
<br /> Distance to neatest: Well oZrSO Foundation 1_!/ Piuperiv Line _
<br /> LEACHING LINE �• No. 8 Length of Imes y^— J
<br /> y� g —.��---------- Total lenptn/situ._
<br /> FILTER BED Cl Distance to nattiest. Well Fuuoddtiun�1 s, Propuny .riu
<br /> SEEPAGE PITS 1 I Depth __ Sita -- -.__ Number
<br /> SUMPS LI Distance to nearest. Well Foundation z Property Line ..
<br /> DISPOSAL PONDS L-1
<br /> 1 hereby Bendy that 1 have prepared this application and that the work will be dune ur dccufdance wmi San Judito-,,. -, 1,. , and
<br /> rules and regulations of Ino San Joaquin County
<br /> Home owner or licensed agent's"nature ccnifies the lollowrng. "I candy trial in V a purlurmance of the .vork for i.- I
<br /> employ any person in such ntannar as to become subject to wuraman's compensation laws of California"Conirdcwr _f ,, „unatur,f
<br /> cenihas the foliowrng:"I certify that in the performance of the work for which th.s permit is issued,I Malt employ parr,,
<br /> tion laws of California."
<br /> The applicants muat etll for all req din petitions. Complete drawing on reverse side.
<br /> LSigned X."'"' - Title.---%-'--_i.�_�=. C.(!�,{ i — „- .• -- -----
<br /> FOR DEPARTMENT USVONLY
<br /> Application Accepted by Dau
<br /> Pit or Grout'Upection by Date Final InspoCtion by
<br /> Additional Comments:
<br /> r Applicant - Return all copies to: San Joaquin Coun'cy Public Health
<br /> °ry r, /--4' r era.1,e.a•L /c o.r Services, Envirocwental Health Permit/Services
<br /> f�rr<r .I,rcy •.c `ti 1601 E. Hateltoo Ane., P 0 box 2005'. Stockton, CA 95201
<br /> FEE INFO _ OUNT DUE AMOUNT REMrTTED CASI hECEWEO
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