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SAN JOAQUIN COUNTY PUBLIC H D vTH SERVICES <br /> ENVIRONMENTAL HEAL <br /> PNE ON <br /> 445 N SAN JOAQUINSTOCgTON(2CA) _95201420 <br /> P O BOX 2009, <br /> PERMIT EgpIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f Y permit to construct and/or install the work herein til described. <br /> Sans <br /> ppplicntion is hereby made.to San Joaquin Count for a Pe Ordinance No. 51+9 and 1862 and the Rules end Regula <br /> application is made in compliance with San Joaquin County i <br /> Joaquin County Public Health Services. ��\Lot Size/Acreage <br /> City <br /> Job Address ice' .- Sol D3 -A <br /> �a` <br /> Phon <br /> Address <br /> Owner's Name - phone <br /> ` ,f. l License No- <br /> ()N Address 4 DESTRUCTION ❑ Out of Service Ffell ❑ i <br /> i Cont+actor WELL REPLACEMENT Monitoring Well L3 <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR RP pp. LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLO. (� <br />` <br /> DISTANCE 70 NEAREST SEPTIC <br /> SEWER'LINES OTHER WELL PITS/SUMPS �) <br /> FOUNDATION --- AGRICULTURE WELL <br /> PROBLEM gREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> INTENDED USE TYPE OF WELL -- "'�^''rDia=of 1Ne1t Ca3iri� <br /> _ Open-Boftom -. - ❑ Manteca = Dia.of Weil Excavaiion Specifications <br /> i Cl lndusiriaal'- ❑ Tracy Type Of Casing_ <br /> Gl Gravel Pack Type of Grout <br /> [.} pomesticlPrivate ❑ pelta _ Depth of Grout Seal <br /> I'1 Public I:1 Other <br /> ' Apprax. Depth I I Eastern Surface aI Installed by <br /> )(Irrigation H P �I State Work Done <br /> Repair Work Done X Type of Pump �U b -- Sealing Material 6 Depth <br /> � + <br /> Well Destruction © Well Diameter � — <br /> Filler Materiel i Depth <br /> Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I k REPA�IRlADDITION I I Di S7flUCTtbN l I ave(No sap system permitted if public sewer i <br /> C <br /> Installation will serve; Residence o merciaf' <br /> "N,7m-f 6f'living-7i r1tt Ndm�°f`badroonl -� ,.,.�' ,04, filter table depth <br /> ! .t _. .= <br /> Character of soil to a depth of 3 feet: .f - ..-� _ No• Compartment$ <br /> Capacity,SEPTIC TANK ❑ Type/Mfg �;- �•.` '�"' s s.Method of Disposal - <br /> I � `•y•. �. <br /> .,r,PKG.,TREATMENT PLT.❑ '� "" Propertrty-Line ,--1---- <br /> a -: Distance to nearest: —Well"- _-i f Foundtian ,.�. <br /> {' <br /> r \ <br /> k t �. Total length!siie <br /> LEACHING LINE ❑ No. & Length of fines Well Foundation - Property Line �— <br /> FILTER BED ❑ Distance to nearest: I T . <br /> Sire Nurriber \ <br /> SEEPAGE PITS l 1 Depth Property.Line — <br /> Foundation <br /> SUMPS Lt Distance to nearest: a Well <br /> r DISPOSAL PONDS ❑ <br /> I hereby certify that f have prepared this application;and that the work will be- accordance with San Jo aquin county,� ordinances.irnij is -jTed laws, and <br /> rulas_and_regulalions of the San Joaquin County__. .wing:I to ' <br /> workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> Home owner or licensed agent's signature certiT+es the fopowin 'I certify that in the performance of the work 1°Frs�ons aubjecteto w°rkman's compel sat <br /> employ any Person in such manner as to become sublet V -�. <br /> certifies the following: -I certify that in the performance of the work far which this permit is issued, I shall employ pe <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawin on reverse side. <br /> r Dater <br /> Title: . <br /> Signed s F DEPARTMENT USE ONLY <br /> Date <br /> ru_&* <br /> Application Accepted by Date <br /> ate Final Inspection by <br /> Pit or Grout Inspection by F <br /> i <br /> Additional Comments: <br /> Applicant - Return all copies to: Epviroumentaln Joaquin oHealthuntY uPermit/Serviceblic Health s ices <br /> Environmental <br /> Joaquin�P 0 Box 2009, Stkn, CA 95201445 N1 <br /> I GK RECEIVED BY �Z�DATEPERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH 4q <br /> INFO <br /> EH 14.26 <br /> + <br />