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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN._JOAQUxX;�=PHONE (209)468-3420 <br /> P 0 BOX 2009, 9T6CSTON, CA 95201 <br /> x PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> Application is hereby made to San 'Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Z i S��-+c, w� `( 5��� <br /> Job Address 1 � i �.1.t� Lot Size/Acreage <br /> i Owner'sName�0e Address 'o-341 S1J�,If_0J&Lgm..#hons <br /> Contractor Address7RO 1?.G k I'{ n License No. 1 (67-3 73 Phone t7 <br /> TYPE OF WELD/PUMP: WEV11tWELL Elly WELL REPLACEMENT _ DESTRUCTION PIDut of Service Well ❑ <br /> J ? LM LiNSTi�La,TIOiV 4. SYSTEM REPAIR ❑ OTHE7 Cl Monitoring Well L� <br /> DISTANCE TO NEAREST: SEPTIC TANK 4- SEWER;LINES DISPOSAL FLD.1099 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CbNSTFtUCTION SPECIFICAT! NS <br /> 14 <br /> 0 Idustria! ❑/Open Bottom © W <br /> Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> fKDomestic/Private Irl Gravel Pack C0] T`r�cy Type of Casing- <br /> Specifications <br /> I') Public i_l Other eIta Depth of Grout Seal ,. 6 y Grout <br /> 1 1 Irrigation — Approx. Depth I I Eistem Surface Seal Installed by LV Zd <br /> Repair Work Done UType of Pump H.A. State rk Done ftf <br /> Sealing Material & Depth <br /> l <br /> Well Destruction ;-"'Well Diameter � p <br /> Depth l — Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION i I (No septic system 06milted if public sewer is <br /> available within 240 festa Q� <br /> 1 <br /> installation will serve: Residence_.(Commercial_ Other <br /> F <br /> Number of living units: Number of bedrooms <br /> ti -94 —Z '� '3�. '�9 �. <br /> Character of soil to a depth of 'fed% � Water table pfh ' <br /> SEPTIC TANK"'-""---- ❑ Type! -'°"" Capacity" "" No:Coin artri� M3 <br /> p <br /> PKG. TREATMENT PLT. 0 Method of Disposal ) <br /> Distance)t,,At4@ t; W .L I Foundation Property Line l <br /> LEACHING LINE 0 No. & Length of lin Total length/size <br /> FILTER BED C) Distance to near Wei _ oundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number ; <br /> SUMPS LI Distan a nearest: Wei undation 4 Property Line a <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the wofR-Wilt-tie done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or ti a <br /> signature certifies the foliowin t <br /> g g g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any on in such man er as to become aubje workman's crj�pensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies t oIlowing: "I certif hat in the pe rme e` the work for whTc h this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion la of Califor a." <br /> Thea plicant c r II "qu' d ' mp to drawing on r ids. i <br /> Signed / Title: � `� hate: r' <br /> r <br /> OR DEPARTMENT USE ONLY �! <br /> Application Accepted byADate • <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date r , <br /> Additional Comments: o? ~ ' /7 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services • <br /> Environmental Health Permit/Services <br /> 445 N San Joaqui x 2009, Stkn, CA 95201 �� <br /> Ar <br /> NEr AMOUNT DUE AMOUNT REMITTED ECEIVEO 8V DATE PERMIT NO. ~ r <br /> IN.FO <br /> . EH13"24 IREV, i n SI <br /> EH t42a fI-r � t�l9 � <br /> W t._ <br /> .+ <br />