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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 Rz� ,Z1V7* <br /> (209) 468-3447 � 'V <br /> ED <br /> Y 3 1992 <br /> (Complete in Triplicate) p�� 'J0AQ1JijN <br /> Application is hereby made to Sats Joaquin Count for f� � COUNTY <br /> County permit to construct and/or inata1�/ ' '` ire{h,r't <br /> application !e trade in cot�,liance with San J ' � hvok,herein,dbArfbed. This <br /> Joaquia County Public Health services. Joaquin County 0rdinnnce.No. 54 and.18b2 and the Rulea naF'R4ii]a�t'i`pt>a,f4gf San <br /> Jab Address d <br /> 00 <br /> City t Site/Acreage, <br /> Owner's Name Address • �,�d � <br /> "--` Phone <br /> c _ <br /> Cantracto ddres �" <br /> TYPE OF WELL/PUMP. ease N{�A26- Phon <br /> _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Kell ❑ <br /> uPUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKC.7 <br /> ..__. SEWER LINES — DISPOSAL DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> LKuornestic/Private 0 Gravel Pack Dia. of Well Casing <br /> L7 Tracy Type of Casing Specifications <br /> [Q Public C1 Other ❑ Delta Depth of Grout Seal <br /> CJ Irrigation Type of Grout <br /> ,� Approx. Depth Q Eastern Surface Seal Installed by <br /> Repair Work Done C! Type of Pump /`���, p- H.p. <br /> Waft Destruction ❑ Wolf Diameter Sealing Material & Depth State Work Dana <br /> Depth ,.f Filler Haterial & Depth <br /> 41 <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION 17) REPAIR/ADDITION M DESTRUCTION G (No-septic s stem 4li <br /> Y permitted if � <br /> available within-200-feeta rbtic sewer is <br /> Installation will serve: Residence_ Commercial :: Other <br /> Number of living units: Number of bedrooms''-`�' <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. O Type/Mfg tie- Water table depth <br /> PKG, TREATMENT PLT. ❑ Capacity No. Compartments Z <br /> Method of Disposal O <br /> Distance to nearer;: Well Foundation :property Line } <br /> LEACHING LINE C"1 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 Depth Sizo­= - — <br /> `.Nurriber <br /> SUMPS LI Distance to nearest: Wolf' Foundation* Property Lina <br /> DISPOSAL PONDS ❑ <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 la <br /> rules and regulations of the San Joaquin County ws, and <br /> Home ownor or licensed agent'rsignature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject.to workman's compensation laws of California." Contractor's hiring Or sub-contracting signature <br /> certifies the following: ' <br /> "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 laws of Californis." <br /> The applicant mus f all require",' lions. Complete drawing on r se side. } <br /> Signed 4 r <br /> I.. <br /> Title. Date: LTJ <br /> FOR DEPARTMENT USE ONLY Application Accepted by 4 Z 2 0 <br /> Da�4�4 Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection b Dats� <br /> Additions! Comments; <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION-PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED ti CK <br /> �0-0 <br /> ,,rr �'ll r - RECEIVED 8Y DATE PERMIT'NO. <br />. EN t3.24 rREV.riss, �� `f CV i 3G.soD r /! QZ Z - 6 <br /> EH 7�•Ze <br />