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INTENDED USE <br />Industrial <br />F.) Domestic/Private <br />11 Public <br />I 1 Irrigation <br />Repair Work Done <br />Wilt Destruction <br />TYPE OF SEPTIC WORK, NEW INSTALLATION I 1 REPAIR/A0DITIONg DESTRUCTION I 1 INo septic system <br />available within 200 feet/ <br />TYPE OF WELL <br />0 Open Bottom <br />El Gravel Pack <br />1.1 Other <br />Approx. Depth <br />(.3 Type of Pump <br />0 Well Diameter <br />Depth <br />PROBLEM AREA <br />Manteca <br />Tracy <br />Delta <br />1 I Eastern <br />H.P. <br />Sealing litateria.1 5 Depth I)! t <br />Tiller Material Deptli-,itin <br />Dia. of Well Excavation PA y Dia. of Well Casing <br />Type of Casing MEAlailications <br /> <br />of Grout Depth of Grout Sea: <br />Surface Seul Installed by APR 1 1 1994 <br />st""YAL.„,.elit•coo NTy <br /> <br />le rIcst, SERVIC <br />CONSTRUCTION SPECIFICATIONS <br />if public sewer is <br />FEE <br />MO AMOUNT DUE AMOUNT REMITTED Wt RECEIVED eV DATE PERMrt NO , <br />- 1 ‘. \fr I I 1 Il i 6e) 094 (7qii a4t/t/te- q-(/- _731 . Sri 1)44 tfiEV. WiS) <br />11-311 <br />APPLICATION <br />SAN JOAQUIN COUNTY PUBLIC HEAL <br />ENVIRONMENTAL HEALTH la <br />445 N SAN JOAQUIN, PHONE (209) <br />P 0 BOX 388, STOCKTON, CA 952 <br />stL <br />timILLmmff,,mmwww• <br /># <br />ERMIT:_:116 IR 1 YEAR FR AI ; r <br />S (Complete in Tr„„c <br />AMP <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described This application is made in compliance with San <br />Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br />Job Address 47 Zo t1 RA/E-- <br /> <br />City Lot size/Acreage <br /> <br />Owner's Name-W—E7VnAl Jai Address <br /> <br />phonspi€37 <br /> <br />PUMP INSTALLATION C SYSTEM REPAIR 3 OTHER 0 Monitoring Well <br /> <br />NEW WELL 0 WELL REPLACEMENT r, DESTRUCTION 0 Out of Service Well <br /> <br />Addr.sS9c.70 N. Lt7cense NoaA4( phone4tI67‘ve <br />0' <br />0 <br /> <br />TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE <br />AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />TYPE OF WELL/PUMP <br />Contract° <br />DISTANCE <br />FOUNDATION <br />Installation will serve: Residence A., Commercial Other <br />Number of living units: t Number of bedrooms S <br />Character of soil to a depth of 3 fart: A 00,63 Watitt table depth <br />SEPTIC TANKAUST- 0 Type/Mfg Capacity No. Comportments <br />PKG. TREATMENT PIT. 0 Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br /> <br />LEACHING LINE No. & Length of linos Total length/size <br />p? <br />FILTER BED Distance to nearest: Well PilZ, Founoation /et Properly Line <br />t <br />SEEPAGE PITS iet\ Depth 4= <br /> <br />Site W/52 Number CrYr-S2-- <br /> <br />SUMPS LI Distanc,e to newest: Well Foundation Property Line <br />DISPOSAL PONDS 0 <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Laws, and <br />rules and regulations of the San Joaquin County <br />Home owner or licensed agent's' 14gnature certifies the following: "I certify that in the periormance of the work for Mich this permit is issued. I 'Asti not <br />employ any person in such manner as to become subject to workmen's compensation laws of Caiifornia." COnlISMOr'll hiring or sub-contracting signature <br />certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall employ persons eubelct to wotkmen's COmpense- <br />tion laws of California." <br />The applicant must call for all req ' iu)d <br />FOR DEPARTMENT USE ONLY <br />ons. Comple drawing op.Lerse side. "Irs_4104.• , <br /> Title: -9-27,-- <br /> <br />DPW:* <br /> <br />Application Accepted by <br />Pit or Grout Inspection by Date <br />Additions! Comments: <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N. San Joaquin, P.O. Box 188, Stockton, CA 95201 <br />- <br />Final Inspection b <br />Date <br />Dete,1" 'HS 133 (2/84)