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1..: - <br /> SAN ,,JAQUIN COUNTY PUBLIC HEALTH .,!dnvimS PAYMENT <br /> Sh'VIRONYEA'TAL HEALTH DIVISION RECEIVED <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 FEB 10 1M <br /> P 0 BOX 2009 , STOCKTON, CA 95201 <br /> SAN JpkMlR COLINTY <br /> I!MIT SPIRES 1 YEAR FRplld pp� 'E ISSII PUBLIC HEALTH SEPvICES <br /> (Complete in Triplicate�VERDNME�IiI�LriZALTt.DlVia10�'2 <br /> Ayplication is hereby wade to Sam Joaquin County for a per=it to construct and/or Install the work herein described This <br /> aPPlication is side In costpliance with San Joaquin Conaty Ordinance Ila 549 and 1862 and the Rules and Regulations or San <br /> ' Joaquin County Public Health Services <br /> Job Address E City S—%D L-K-TCtJ Lot Size/Acreage <br /> C't1e�.4r_00 l?7!c QD 3y, 500w\ 3 <br /> ' Owner's Name Szvd.� Address S fVVC(MC►� /'� Phone C I D r 7 Q <br /> (GV l L.F{N6 w fyu— k W^ LA"Dt ry X LrJ . S(a <br /> contractor�1�� ►�U r0 Address ro t- License No Phone 6 <br /> ' TYPE 0€ WELL/PUMP NEW WELL WELL REPLACEMENT Ci DESTRUCTION ❑ Out Of AerX1re .kW.;_�1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O ait:orl.4 Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES •Sa f� _ DISPOSAL FLA r PROP LIN <br /> FOUNDATION AGRICULTURE WELL —-e-- OTHER WELL_ PITS/SUMPS X= <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bonom O Manteca Du of Well Excavation Dia of Well Casing + +� <br /> YI�P_Drrwslm r e .Gravel Pack ❑ Tracy Type of Casing SCI-t An t'-4 C_ Specifications <br /> ' f I Public n Othqr n Deka Depth of Grout Seat " Type of Grout <br /> I I Irrigation Appros Depth I 1 Eastern Surface Seui $nstalled by'D.F=N -- 4Tt= <br /> Repair Work Done D Type of Pump KP State Work Done <br /> ' Wall Destruction O Well Diameter Sealing Material i Depth <br /> Depth I-ff== Piller Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted of pubbe sewer is <br /> evadable within 200 lint M rn <br /> PlnstOlistbOn wilt siva Residence_ Commercial Other <br /> Nurnbw of Irving unit: Number of bedrooms <br /> Character of sog to a depth of 3 feet Water table depth <br /> ' SEPTIC TANK 0 Type/Mfg Capacity No Compartments � <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> ante to nearest Well Foundation Property Line <br /> ' LEACHING LINE CI No & Length of lines Total len <br /> FILTER BED I❑ Distance to nearest Well Fou Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS tanto tp nearest Well Foundation Property Line <br /> DISPOSAL PON o <br /> jtrhersy conity that I have prepared this application and that the work will be done n accordance with San Joaquin county ordinances state laws and <br /> les and regulations Of the San Joaquin Countyome owner or i"nsed spent It i ignsture certifies the follomna 'I certity that in the performance of the work for which this permit is issued I shaft not <br /> employ any person M such manner as to become subiect to workman s compensation laws of Cablorriu Contractors hiring or sub-contracting sipnatuta <br /> cartifies the following I certify that in the perlom%ance of the work for which this perrrrl is issued I shall employ persons subject to workman s compenss <br /> ' bon Yaws of Urfornla " <br /> The amust rag far required inspections Complele drawing on reverse side <br /> Sigined Title C*­1 S� _._ Date 1 s <br /> ' FOR DEPARTMENT USE ONLY LOP <br /> Application Accepted by LAQDate r Area _C_n_j <br /> Pn or Grout Inspection by Date Final Inspection by Date <br /> ddrtionoI Comments <br /> Applicant - Return all copier; to San Joaquin County Public Eiealtb Ser%ices - _�1 f <br /> Encp <br /> iroe,eatal Nealtb Permit/Seri lceis F WP l 7 1903 <br /> 445 h San Joaquin, P O Boz 2008, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED ISY DATE PERW7 NO <br />