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FOR ERMIT <br /> ON <br /> SAN JOAQUIN COUNTYIPUBLIC HEALTH SERVICES RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION JUN 2.3 1992 <br /> P 0 80% 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ENVIRC)NfAENTAL HEALTH <br /> REM IT "YDIRRR 1 YEeT3 P$^u DAfiB ISSU7dl PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby made to Sac Joaquin County for a Permit to construct and/or install the work herein described. This <br /> application is ande in compliance with San Joaquin County Ordinance no. 569 and 1862 and the Rules and Regulations of Sen t <br /> Joaquin County Public Health Services. <br /> City,a J 4 Lot Size/Acreage <br /> Job Address <br /> ( Address �OZ-. r Phots <br /> OS/License N ��j��''�' }}��2� , Pnone <br /> Conuat��A�4"�� �es���lb bid4k ir�- <br /> TYPE OF WELUPUMP: NEW WELL ❑ / WELL REPLACEM ❑ENT DESTRUCTION C3Out Of <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ Service ell C]L.-+.�/ OTHER ❑ Monitoring Well <br /> �.� <br /> --DISTANCE TO NEAREST: S£PTtC-TANKy . SEWER LINES DISPOSAL FLD_. PROP. LINE — <br /> - —^pIT�ISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Ind i 1 O Open Bottom 15Manteca Dia. of Wag Excavation Specifications <br /> ortsatic/Privets ❑ Gravel Pack ❑ Tracy TYPa of Casing <br /> M Public - O Other O Dene Depth of Grout SNI Type of Grou[ <br /> Ci Irrvatron i' ' € —APtwox. Depth ❑ Eastern / SwHiG Sasi Intalled by <br /> "'� ` ]��/� Stara Work Oats <br /> Repair WO/F09M U Typo of Pump dsesa—, H p.Healing Material i Depth \ <br /> Wag Den�ruction... ❑ Wee Diameter Filler Material a Dayth <br /> Depth <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDIT(ON 0 DESTRUCTION Cl INovailable vnt�n 200pfM permitted ii pontic sewer is <br /> �. Installation wig serve: Floods""_ Commercial— Other <br /> Number of living units: __ Number of badtooma <br /> Witter fable depthCharacter of one to a depth of S fast: <br /> SEPTIC TANK. C) Type/Mtg Capacity No. ComPan"nts <br /> PKG. TREATMENT PLT,❑ Method of Disposal <br /> .. Distance to namt: Well Foundation. Property Lin J <br /> ``.{EACHING LINE L1lin <br /> No. d Length of es Total lengthlsizY <br /> FILTER BED ❑ Distance to nares: Wap Foundation Property Llni <br /> 4 <br /> SEEPAGE PITS I i Depth �'�" Sire Number <br /> SUMPS LI Distance to r*W"I: Wen Foundation Property Lira <br /> 1 DISPOSAL PONDS O <br /> f I hereby certify that i haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances. Nat*terms, and <br /> was and regulations of tie San Joaquin County <br /> Home owner or licensed agent's signature ceniNss the following: "i urtify that in the performance of Ins work for Which this permit K jawed. 1 shag has <br /> employ any person in such manner.n to become wbpct_lo.workmada wmpensstionJawa.of�NiforOia.'-Contractors hiring or sub-contraciin9 ngnatwe <br /> cenifiee the following: "I cardty that in the performance of the work for which this Permit la issued, I shali emPicy Forfeiture aubieat 10 workman's comnsnas- <br /> tion laws of Calitorrda." <br /> The applicant or 11 required in pec'qua--ComPlsta drawing�qqfvv•ersv side. �,y✓ ¢ <br /> f Signal .� TNN: Date: <br /> i FO�IPARTRiENTUSE NLY / <br /> _ a <br /> Application Accepted by --- D*ts Arae <br /> Pit Or Grout inspection by <br /> Data Final Inspection by Date <br /> - <br /> Additional Comments: <br /> Applicant - Aatuty all copies to: EEVICES <br /> NVIRONMENTAL {t "THUBLIC HEALTH MDIVISIION pERMIT/SERVICES <br /> w 446 N SAN JOAQUIN.-P O "Uk You". D'tocK'roa. CA 96201 <br /> FEE AMOUNT DUE 1 AMOUNT REMITTED C bH RECEIVED a PATt PERMIT-NO. <br /> FD • r Q <br /> . 1"13 2*'Rev I..u A( ! I l /J <br /> EH l4a <br />