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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUINE (2CA)95201420 <br /> STOCK <br /> TON,O BOX 2009, ; <br /> •i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Trip licate) <br /> � <br /> Iermit to construct and/or install the work herein described. This <br /> Application is hereby made.to San Joaquin County for a p >+9 and 1862 and the Rules and Regulations of San <br /> application is made in compliance with San Joaquin County Ordinance No. 5 <br /> Joaquin County Public Health Se1ry ces. �L_ <br /> Lot Size/Acreage <br /> City KPA <br /> AA ; <br /> Job Address ► Ci <br /> O � <br /> A r ss <br /> Np/afm�,/n <br /> Addr <br /> 'License <br /> No. Pjh <br /> o tractor DESTRUCTION ❑ outice Well ❑ <br /> NEW WELL WELL REPLACEMEN ❑ OTHER ❑ ing Well ❑ <br /> TYPE T WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION DISPOSAL FLD. PROP,SEWER LINES _�-�---- p17SlS � <br /> DISTANCE TO NEAREST: SEPTIC TANK —'=- AGRICULTURE WELL OTHER WELL—----- <br /> FOUNDATION -- <br /> INTENDED USE TYPE OF WELL , PROS-LO EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> "y Cl-Manteca Dia. of Well Excavation <br /> C} Industrial ❑ Open Bottom_ Specifications <br /> C] Gravel Pack " ❑ Tracy Type"of Easing_ Type of Grout <br /> I'] Domestic/Private, 1 r it Delta Depth of�Grout Seal r <br /> 1-1 Other ' <br /> IF <br /> i'1 Publicj � i �"' 'rface Seal Installed by <br /> Approx. Depth I Eastern <br /> igation State Work Do <br /> Repair Work Done L] Type of Pump _ / Sealing''Msterial 3•';DSpth <br /> Well Destruction ❑ Well Diameter Filler Material S Depth <br /> Depth . ,_.. <br /> Iavailable within 200 feet.! <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR!ADDITION-.I�I`�!t?ESTRUCTION l I INo septic system permitted ii public sewer is <br /> Commercial Other <br /> Insiellation will serve: Residence! a. x .: <br /> F� Nuiritier'bf living units:- ' Number_of-bedroorns �-;-'= Water table depth <br /> Character of soil to a depth of 3 feet: Caps qty • No. Compartments + <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal 1�` <br /> PKG. TREATMENT PLT.❑ _- <br /> Property Line�--- <br /> ' � <br /> r Distance to nearest: Well Found <br /> � �` F alio <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of IinaB. Foundation Property Line <br /> FILTER BED p-.-.Distance to nearest: Well " <br /> 4 <br /> - 1 Size - Number <br /> SEEPAGE PITS 11 bepth Property Line <br /> Foundation-- <br /> SUMPS LI Distance'to nearest:-- <br /> well o <br /> DISPOSAL PONDS t © ' ' - <br /> ! I hereby certify that ! have'prepared this application end that the work wi1ll a done in ac rdance with San Joaquin county ordinances, state 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 which this permit is issued, 1 shall not <br /> that in-the.performancs of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> employ any person licensed <br /> manner-as to become subject to workmen's compensation laws of..Cal'Jornia.' Contractor's hiring or sub contracting signature <br /> certifies the fallowing:;'!_certify. <br /> tion laws of California.`' tof� <br /> ctions. Complete drawing an rev side. <br /> The applica t st call to all aired.inspe, ► pate: <br /> i Title: <br /> Signe i r <br /> FO EPARTMENT USE ONLY <br /> l ! Area <br /> Date <br /> Application Accepted by r Data <br /> , Final Inspection by <br /> Pit or Grout Inspection by Date -- <br /> I � + - <br /> Additional,Commentr. <br /> tVN <br /> EnvironmentaloHealthuPermit/8ervicesv ccs <br /> Applicant - Return all copies to: <br /> l 445 N..San-3oaquin, P 0 Box 2009, Stkn, CA 95201 <br /> K ► RECEIVED By DATE PERMWISIO, <br /> AMOUNT DGE AMOUNT REMITTED CASH <br /> AFEE <br /> . EK 19-24(REV, <br /> EH 14.26 <br /> F <br />