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SER <br /> SAN JOAQUIN COUNTY PU13LICEALTHION VICES PAYMENT <br /> -� <br /> ?1, 445 <br /> ENVIRONMENTAL N SAN JOAQUIN, PHONE (209)468-3420 RECEIVE D <br /> P O BOX 2009V STOCKTON, CA 95201 pN 1993 <br /> E ISSUID SAN J0AQUIN COUNTY <br /> 1 PERMIT EgPiRES 1 YEAR FROM DAT <br /> SER I r: <br /> PUBLIC HEA <br /> (Complete in Triplicate) HEAL <br /> Z ,. <br /> urn County for a permit to construe and/or instal the Re Regulations of Ban <br /> Application is hereby conplo Sannce Joao _��Z, <br /> application is made in compliance with San Joaquin County Ordinance No. 5 9 4 <br /> Josquin County Public Health Services. a&,�� <br /> Lot size/Acreage? <br /> C,,y <br /> Job Address Phone - a <br /> 11 11 I'll 4,64-tv11 <br /> Address <br /> s Owner's NameZta Phonel-026-_ S <br /> License No. <br /> `�t `. . r " ' r . Address ' Well 0 <br /> Contra( WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Monitoring well <br /> F NEW WELL ❑ OTHER -C) <br /> TYPE OF WELL/.PUMP: SYSTEM REPAIR ❑ PROP. UNE <br /> PUMP INSTALLATION D DISPOSAL FLD. <br /> SEWER LINES .�----� P175lSUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �--� AGRICULTURE WELL OTHER WELL�r--� � <br /> FOUNDATION �- - <br /> �.+T-YPE-OF WELL . PROBi__EM AREA GONSTRUCTkON SPECIFICAI,IONS - �� # <br /> - - INTENDED <br /> -USE-- -= ❑ Manteca Dia. o I <br /> ❑ Open Bottomrp ��'`T <br /> Cl Industria! ❑ Tracy 'type of Casing-_ , Q ,✓' <br /> [I Domestic/Private Ci Gravel Pack n Delta Depth of Grout St� 91[V1F1 <br /> I'] Public 1-1 Other <br /> Surface Saul insta b <br /> l I Irrigation —Approx. Depth I I Eastern State Work Done <br /> Type of Pump -- H.P. ' <br /> Repair Work Done U Sealing Material & Depth _ � •, <br /> Well Destruction ❑ Well Diameter Filler Material & Depth �J <br /> f Depth <br /> available within 200 feet.!, r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ! EPAIR ADDITION RESTRUCTION l I (No septic system permitted it pub+c sewer + V 7 <br /> e: Residence <br /> �' ;', Commercial Other <br /> installation will sery �1 . - - '° <br /> ��` w -'-�""""'""T <br /> —Number of living units: �:Number.nf- a roomsf Water table depth Q <br /> Character of soil to a depth of 31ee1: ti Capacity—.l,fes--- <br /> OCU No. Compartments <br /> SEPTIC TANK. TypelMf9 " Method of Disposal, <br /> PKG. TREATMENT PLT:.C1,� Property Line _---- <br /> �--- <br /> rl� <br /> < .s gistance,to nearest: Well Foundation . <br /> Total length/size <br /> LEACHING LINE Cl No. & Length of lines Property Line <br /> �,paundation ,���--- <br /> FILTER BED Cl Distance to nearest: Well <br /> x!c <br /> -' Number r <br /> SEEPAGE PITS Depth 'S Size <br /> 'F Foundation/ Property <br /> ' SUML1 Distance to nearest: Well —44 -. <br /> DISPOSAL PONDS ❑ t t <br /> - hereby c�rtifY-that!'have;prepared this application ahd thar�the work w�1T"be coo e-+n accordance with San Joaquin county ordinances,state-taws, and'r <br /> rules and reigulatiohs of the-Sin�"Joaquin.County v rformance of the work for which this permit Is issued, ! shall not <br /> Home owner or,ficensod agent's signature certifies the following: -I certify that in the pe <br /> employ any pe in tfte rformance t the(kmaio�`which this permit is issued, I shall employ persons subject to workman's compensa- <br /> 1 { person in such manner as to become subject to workmen,s•cornpensaticin laws of California." Contractor's hiring or sub-contracting signature <br /> ork <br /> certifies she following: "i certify that in <br /> ' tion laws of California." 1-1 <br /> The applicant t call for y uir inspetaions: Complete drawing an reverses i Date: <br /> Title: <br /> Signed <br /> t �'�" FOR DEPARTMENT . $E ONLY �� ,� <br /> I _ - Data '!� Area <br /> Application Accepted by- Date <br /> Final C <br /> l inspection by <br /> i Pit or Grout Inspection by-.1' r Date <br /> Additional Comments: �,,i► n <br /> Environm <br /> Applicant Return al1_copies to: _San Joaquin County Public Health Services f -"9 �f1 <br /> entalh Permit/Services <br /> 445 N San JosqHealtuin, P 0 Sox 2009, Stkn, CA 95201 <br /> CK RECEIVED 8Y DATE PERMIT NO. <br /> i FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EM 13.24(REV.+1+151 ,V, <br /> EH 14.25 <br />