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1 SAN J r 0HEALTH <br /> IN COUNTY PUBLIC S�.�IC&S <br /> �ylgp�TAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, <br /> PRONE (2CA} 461424 <br /> P 0 BOX 2009, STOCKTON, <br /> (Complete in Triplicate) <br /> A�pplt4at1onSR bereby aarde,to San Joaquin county and/or <br /> for a permit to construct install the cork herein described. This <br /> GvWeatioa is gado in coa*].iance vith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Comtel' Public Health! Services. �+p�/� <br /> Job Address i32- toj� 1�• � A�� Z City ��" Lot size/Acreage <br /> �N Rawc�xa 9415 <br /> Owner's Nana '�- <br /> fit((js Dever � �C�•.ae ?.JJ� Mi ss�an r r Phoma <br /> contracter <br /> 4 +yin Address ^� r S�aL�L+'cense Noll Phone f�7i <br /> TY q WELL/PUMP: NEW WELL WELL REPLACEMENT C1 QESTRUCTiON D Out o! Service Yell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ Mositorirlg well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �.. DISPOSAL FLO. PROP. UNE <br /> FOUNDATION _. AGRICULTURE WELL OTHER WELL_2&__ PITS/SUMPS .^ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS at <br /> C1 bxkn&W ❑Open Bottom ❑ Manteca Dia. of WON Excavation Dia. of Was Casing <br /> n Danns w Private x Gr" Pack ❑Tracy Type of Ca*V&12, SD <br /> E'I Publlc _� I:'] Other n DMta Depth of Grout Seal [D Type of Grout + <br /> 1 krigstion�Msrti16 Approx. Depth )(Eastern Surface Seal Ins ow by <br /> Repair Work Done U Yoe of Pwnp H.P. State Work Done <br /> Wain Oesiruction ❑ WW Diameter Seeltag Maternal 3 Depth <br /> Depth Tiller material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR I ADDITION I E DESTRUCTION I I IND spfio syslam ppearrnrnwwtttod if pubk sawn a <br /> aveitM><e Within 3001eet.1 <br /> Watef cion wi sera: ft-1,1-n-- __ Corrunercirl— Other <br /> Number olwvinq unite• --- -- Number of bsdroortle <br /> Charact r of Mo to a depth of 3 bee: water tabic depth <br /> SEPTIC TANK. ❑ Tvpo/Mfg Capacity No. Competnw o <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Dietanee to nearest: WeN Foundation Property Line <br /> LEACHIM LOA CI No.!Length of km Total Nngth/size <br /> FILTER BED ❑ Distance to sweat: WW Foundation Property Line <br /> SEEPA41 MTS I I Dapth Size Number <br /> SUMPS LI Distance to nearest: Wel Foundation Property Lire <br /> DISPOSAL PONDS 0 3 <br /> I Iwrby certify that I have prepared this gwkabn end that the work wdI be done in accordance with San Joaquin county ordenences, stets Ism, and <br /> n n and regulatiorw of the San Jo ouin Cousty <br /> Horne arsnsr or Me- - eoett's aigneture certifies the following: "I certify that in the pefonnanoe of the work for which this permit is issued.I OW not <br /> annpbr any pare, in such froom es to', ,, w abject to workman's oomperwetion Was of Caaforris."Comractors hiring or sub-eanaeetirfg signature <br /> certifies the fobvAngg•'I artily that in tin pwfommca of the work for which this permit is iw,ed,I shah employ persons subject to workman•a compenaa- <br /> don loan of CaNNa ds." <br /> The ppliceet inim case I Inspections. Complete drawing an reverse skis. <br /> q�.–� <br /> Signed x Title SQ�/11bir f'l.50GtasJt"e.,. Data: <br /> FOR DEPARTMENT USE ONLY <br /> Appks§on AeomIndby a � A,s ro 9,00 <br /> PN or finprt Irtiap.cion a t. Final inspection by Dain <br /> Adeltl M <br /> S& <br /> Applicant - Return all coplos to: San Joaquin County Public Health Services <br /> Hatirouesntal Healtb 4erait/Services <br /> 443 N San Joaquin, P 0 box 2009, Stites, CA 95501. <br /> RiPO <br /> AMOUNT DIM AMOUNT N&ATTED RECOVED/Y DATE PERiNIT'NO. <br /> . <br /> IN,3-34 tflar.,,.o <br /> Aar, i 3 <br /> Ent u-M <br />