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APPLICATION FOR PERMIT <br /> REC <br /> LIAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 001VE ` <br /> ENVIROMMTAL HEALTH DIVISION <br /> r <br /> APR 15 1993 445pNOS�g.T2009INSTPHONE <br /> (X9)95203420 <br /> � <br /> ENVIRONMENTAL �fEALTh� <br /> PERMIT/SERVICES SIT Fs%PIRTsS l Y,TsAR FROM DATE ISSIIED <br /> (Complete in Triplicate) <br /> fI Application is:.hereby "de to San Joaquin County for a <br /> application is made in cOWliance with San Joaquin County ordinancermit to nNo. 549struct aandol$62aand thetau eRules andvork eRegulatiotsin sdof'13ans <br /> Joaquin County Public Health Services. <br /> f Job Address Ito —,44AJP City Lot Size/Acreage <br /> Owner'sName(�� ( [ �-i—X!FAddress ,(Jr .z <br /> a <br /> Contractor AddressPhone <br /> zo <br /> License No.l�4� (,�( <br /> �,.��f <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE6�j3�'-tA.i -. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open eonom D -Manteca <br /> Dia. of Well Excavation <br /> i �mestic/Private ❑ Gravel Pack Dis. of Well Casing <br /> i ❑ Tracy Type of Casing_ °r ��AiL <br /> I.1 Public Cl Other n Ita Specifications <br /> Depth of Grout Seal <br /> I I Irrigation ,,Approx. Depth V EasternType of Grout r' <br /> Surface Seal installed by �p" � <br /> Repair Work Done L] Type of Pump H P <br /> WON Destruction ❑ Well Diameter Sealing Material i Depth State Work pone �� �-•^ <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION I I DESTRUCTION [ I Mo septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other available within 200 feet., <br /> �� <br /> Number of living units: Number of bedrooms <br /> Character of SON to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Typa/Mfg CspacitV. No. Compartme is ' <br /> PKG. TREATMENT PLT,❑ <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation_ Property Line <br /> LEACHING LINE O No. b Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundation� <br /> Property Line <br /> SEEPAGE PITS ( I Depth Size <br /> SUMPSi:l DiNumber <br /> Distance to nearest: Well Foundation i <br /> DISPOSAL PONDS ❑ --- Property Liner <br /> I hereby certify that l 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 signature certifies the following:"I certify that in the performance of the work for which this I <br /> employ any porton in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-cont actin I shall not <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to B signature <br /> tion laws of California." p y persons subject to workman's compansa- <br /> ure <br /> The applicant a call r ked In I <br /> spec' ns. Complete drawing an reverse side. <br /> Signed " Cres <br /> Title: � r <br /> Date: ��•/S <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by <br /> Date <br /> Pit or Grout lnspection by <br /> Rate� Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies ta: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 , <br /> FEE AMOUNT OVE AMOUNT REMITTED CK <br /> INFO (�+� CASH RECEIVED PY DATE F�RIT'NO,EM 132 tREV,ural f`/(� � +QEN 1626 V f / t/ <br />