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IC HETH <br /> SAN jOAQUIN CNME TAL HEALTH DIVISIONRVICES <br /> ENVIRONMENTAL PHONE 209)46$-3420 <br /> 445 N SAN �IOAQUIN, <br /> p 0 BOX 2009, STOCgTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU <br /> ID <br /> Triplicate)Tri <br /> (Complete in p <br /> permit to construct and/or install the work herein described. This <br /> Application is hereby made to San Joaquin County for s p L and 1862 and the Rules and Regulations of San <br /> application is made in compliance with San Joaquin County Ordinance No. 549 ` <br /> Joaquin County public Health gerviCes. Lot Size/Acreage <br /> Job Address Phone <br /> Address 2, <br /> 11, - 7,j <br /> caner s Name Phone_ <br /> • iUeo, <br /> e" ESTRUCTION Ci Out of Service Well C1 <br /> a tt for WELL REPLACEMENT .. Monitoring Well 0 <br /> IOTHER O <br /> TYPE Of ELL/PUMP: / NEW WELL ❑ SYSTEM REPAIR: PROP. LINE <br /> PUMP INSTALLATION 11 `DISPOSAL FLD. _ <br /> „° SEWER LINES -----�' OTHER WELL <br /> PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �---�- AGRICULTURE WELL <br /> FOUNDATION �--- - <br /> TYPE OF PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> INTENDED USE ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Open Bottom <br /> til Industrial ; - Type of Casing_ <br /> ❑ Gravel Pack ❑ Tracy Type of Grout <br /> DomesticlPrivate r..,.. n Delta Depth of Grout Seal <br /> to Other <br /> I'I Public Surface Se <br /> t <br /> ��Approx Dept 1 EasterSeatInstalled by <br /> { t I Irdoation.0 .� , H.P. State Work Done <br /> ! Repair Work Done U Type of Pump Sealing Material i Depth <br /> Welt Det ction ❑ Well Diame Filler Material 6 Depth <br /> Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR.LAODITION I l DESTRUCTION l I (No septic system permined i1 pub ick war a <br /> 1-- <br /> i. x '� <br /> Installation will serve: Residence 'Commercial Other lIJ <br /> Number of living units: Number of bedrooms ' Water table depth <br /> Character of soil to a depth of 3 feet: Capacity ----- No. Compartments <br /> LP <br /> SEPTIC TANK ryp.,,,TIM�9s �"..� Method of Disposal <br /> III TREATMENT PLT. ❑ Foundation��--- Property Line <br /> Distance to nearest: Well ;_-- V <br /> Total length/size <br /> I ---'LEACHING LINE ❑ No. & Length OVInes- � Foundation Property Line <br /> FILTER BED <br /> In Distance to nearest: Well z <br /> ~ SizeNumber ; <br /> SEEPAGE PITS I k Depth <br /> � <br /> SUMP-S � L��istance�to_nearest:,.-Wall..�.��- - <br /> s, and <br /> DISPOSAL PONDS ❑ C <br /> i hereby certify that L have prepared this application and that the s 18 <br /> work will be done in accordance with San Joaquin county oretm+[cssssued I shall not •� <br /> t I he e y /A <br /> rules and regulations of the San Joaquin County g, <br /> Home owner or licensed agent's signature certifies the.follow I certify that in the performance at the work for which this p signature t; <br /> employ any person in such manner as to become su ce of the workafor wh chthis compensationn's laws <br /> is issued, I shall employ persons�sublec{t to wcorkman�acompan6a <br /> certifies the following. "I certify that in the pe <br /> I tion laws of California." ' <br /> 1 The apRlican t cal for all ed inspektions. Complete drawing2revside. <br /> Date: <br /> Title: <br /> Si d RD pUSE ONLY Z <br /> ` Date .- Area <br /> G <br /> Application Accepted by Date. Final inspection b �- Date <br /> ` Pit or Grout Inspection by <br /> y i <br /> 4 Additional Comments: <br /> Applicant - Return all copies to: EnvironmentaloHealthunty ublic Health vices <br /> permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 �] <br /> CK }{ RECEIVED By DATE PERMIT N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED CAEr __7 <br /> INFO <br /> + EK 13-24(REV,I/KSI �� 1+ C"/�J <br /> EH 14-26 I ' <br />