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4 <br />SAN JOAQUIN COUNTY PUBLIC ITRALTH SERVICES <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P 0 BOX 2009, STOCKTON, CA 95201 <br />ENVIRONMENTAL HEALTH DIVISION <br />PERMIT EXPIRES 1 yEAJt FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby made ,to San Joaquin County for a perrat to construct and/or install the work herein described. This <br />applicatiOn is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />J uin County Public Health Services. <br />CitY Lot Size/Acreage 3 3 '\C-Z.€ DLTC <br />Job AciCte2[s W <br />832 - isui9 <br />Monitoring Well 0 <br />DISTANCE TO <br />Dia. of Well Casing <br />Specifications <br />) <br />Filler Material & Depth <br />Water table depth <br />Owner's Name <br />Contractor —Fe/ <br />TYPE OF WELL/PUMP: <br />INTENDED USE <br />CI Industrial <br />El Domestic/Private <br />i'l Public <br />I Irrigetion <br />Repair Work Done <br />Well Destruction <br />TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I <br />Installation will serve: '-Reside ce _I/Commercial ..,,Other <br />Number of living-units: _ Number of bed.tooma <br />AA) 4S Character of soil to a depth of 3 feet' <br />SEPTIC TANK Typti/Mfg <br />PKG. TREATMENT PLT. 0 <br />Distance to nearest: <br />CA41-61te Address <br />NEW WELL 0 <br />PUMP INSTALLATION 0 <br />NEAREST: SEPTIC TANK <br />Lek4J SA <br />y <br />1-1 Delta <br />—.Approx. Depth „.(1,1 Eastern <br />Type of Pump /- <br />Well Diameter <br />Depth <br />0 Manteca <br />0 Trac <br /> <br />.,.'- DISPOSAL FM), PROP. LINE <br />_,W <br />— <br />..., <br />FOUNDATION AGRICULTUREELL OTHER WELL PITS/SUMPS _ <br />r. <br />TYPE OF WELL PROBLEM AREA ,/CONSTRUCTION SPECIFICATIONS <br />0 Open Bottom Die.. of Well Excavation <br />0 Gravel Pack Type of Casing _ <br />." <br />;71 Other Depth 'of Grout Seal Type of Grout <br />SurlaciSeal.•Installed by - . <br />H.P. ..i-2 State Work Done - <br />Sealing Material & Depth ''' . •••:, <br />./ <br />t <br />7 <br />Capacity___L2-7-:.‹ No. Compartments <br />I.NA I iMethod of Disposal <br />Well I 4- Foundation—? Property-Line-20 <br /> Phone <br />/50 &Tit iu Atkis.en4 N0.9S37/ 8 ?tone <br />of Service Service Well <br />WELL REPLACEMENT 1-17-- DESTRUCTION 0 Out <br />SYSTEM REPAifrEi • OTHER 0 <br />SEWER LINES <br />DESTRUCTION I I (No septic system permitted if public <br />. availabte-within-200 feet.) <br />sewer is <br />lo <br />Eli No. Si Length of lines 0 Total length/size s <br />Cl Distance to nearest: Well /Mt -17 Foundation '<-2 .0 P-rtierty Line C>1 <br /> <br />SEEPAGE PITS I I Depth Sire <br />SUMPS LI Distance to nearest: Well <br />DISPOSAL PONDS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with-S.TriJaa-qiiin county ordinances, state laws, and <br />rules and regulations of the San Joaquin County <br />Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of thit work for which this permit is issued, I shall not <br />emplOy any person in such manner as to become subject to workmen's compensation laws of California." Contractor's 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 subject to workman's compensa- <br />tion lave:sof California." <br />j <br /> Number <br />Foundation Property Line <br />0 A <br />. Complete drawing on reverse side. - WA) eol., Title: Date:".' <br />Area <br />Date Final inspection by <br />Additional Comments: /102tr.--r, 1.0 i A. 0 -,P14-47 e- ,,..<4:7..g — 7 /2e <br />U° <br />Applicant - Return all copies to: San Joaquin County Public li CBS <br />Environmental Health Permit/Services <br /> <br />N Sarv..Joaquin.,-.13-0-Box...2009,....StknI-XA,-95201- <br />The applicant must call for all too <br />Signed X <br />" Application Accepted by <br />Pit or Grout Inspection by <br />F DEPARTMENT USE ONLY <br />OA, <br />inspect <br />Date (t) <br />Date .172-z/92- <br />EH 13-24 (REV, lin54 <br />Eli 14-213 <br />FEE ,AMOUNT DtJE .AMOUNT REMITTED \.-,..N. . -- . C.e.sesti____VCK i RECEIVED BY ATE PERMIT'NO. <br />INF54. , <br />NJ <br />, <br />/./.4‘e "7/ <br />..-. ..", <br />AP- CS:2/ <br />LEACHING LINE <br />FILTER BED