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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAOQODUIN, PHONE (2CA}95201420 <br /> 09 <br /> P O BOX , <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> work <br /> in <br /> Application is s hheerrebynmadee.tlolaSann Voshuiz County noco tyrmit constructto and/or <br /> oinstall e <br /> ordinance No. 549and1862and the Rules and described. <br /> Regulations of Sans <br /> application <br /> Joaquin county Public Health Services. ^� <br /> City Lot Size/Acreage <br /> Job Address f ��y,v.�1n s S Q p ► <br /> 1 3 . 5 3(r�k,` a✓r�"Y[ddiesss l r Phone y <br /> Owner's Name <br /> {� ry` ��. , Lt�1 �� I� ^� `tS� Phone3 -�7� <br /> K Address -(J t ._L- a License Nose <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well Cl <br /> TYPE OF WELL/PUMP: NEW WELL LJ OTHER ❑ Monitoring Well �� <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ <br /> ' ---a-- - jSEWER TINES T =-=. -DISPOSAL'FLD"PROP."L'INE`�—- — 9 <br /> ` -DISTANCE-TO-NEAREST-SEPTIC-TANK'`, OTHER WELL PITS/SUMPS <br /> FOUNDATION ____�� AGRICULTURE WELL <br />` TYPE OF WELL EPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE .r.^----. pia. of Well Casing <br /> ❑ Open Bottom CI Manteca Dia. of Well Excavation <br /> C-1 industrial Specifications <br /> [-] Domestic/Private Ci Gravel Pack Type of Casing- <br /> C7 Tracy ng_ <br /> Depth of Grout Seal Type of Grout <br /> !:1 Other r7 Delta \ <br /> i'l Public r Surface Seal Installed by vJ <br /> I I trrigation _.Approx, Depth 4 I Eastern tate Work ne R - <br /> H.P. O►� <br /> Repair Work Done L7 Type of Pump, z,-- Sealing Material & Depth 1 <br /> Well Destruction Well Diamet <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR1Ap01TION I I DESTRUCTION I I availableJNo +wit hin 200 feet) d +! Pt+blit sewer is <br /> is <br /> Installation will serve: Residence Commercial^ Other <br /> Number of living Unita: Number of bedrooms Water table depth <br /> Cha atter of soil to a depth of 3 feet: <br /> Capaeity�� - No. Compartments <br /> SEPTIC TANK © Type/Mfg - _ Method of Disposal <br /> PKG.-TREATMENT PLT. Cl Foundation Property Line= <br /> Distance to nearest: Well . �. f <br /> Total length/size <br /> LEACHING LINE Ll No. & Length of lines <br /> FILTER BED (:] Distance to nearest: Well <br /> Foundation Property Line <br /> Size Number <br /> r 5EEPAGI~ PITS 11 Depth '-� <br /> SUMPS <br /> ��.,"..,_,_„LI�...Distance_to.nearest:�,,,.,,.Well_ ...Foundation. - TP�roper�Y_Line, ----.�=�---�°'���""'Y'� <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 and regulations,pf the San Joaquin County <br /> the following: "I-certify that in.the.performance of the work for which this permit is issued, I <br /> Home owner or licensed agent's signature certifiesnsation s of shall not <br /> employ <br /> the following:ersoin such <br /> certify that n the performance oso f tobject workman's <br /> work aforwhich ethis permit irs issued, I shat!employ persons rsubj subject to workman's compensa- <br /> t 0° <br /> tion laws of California." <br /> The aPZ4271� <br /> iomlete drawing on reverse Is - 3dza,Title: _ `- Date: Oa. <br /> Signer F R DEPAITMENT USE ONLY <br /> 3 ' ..- l <br /> Date Area <br /> Application Accepted by <br /> I Pit or Grout s ctior by ` Date <br /> 511��r Final inspection by Dat° <br /> Additional n <br /> N f3 <br /> Applicant - Return all copies to. ..San Joaquin", c'Health Service <br /> Environmental Health Permit/Services <br /> 445 X San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CKRECEIVED BY DATE PERMiT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> EH 134{(REV.I/ (rf r E7 <br /> EH I{•26 <br />