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- "=--+ APPLICATION FOR PERMIT <br /> ra vt <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESZud <br /> ENVIRONMENTAL HEALTH DIVISION RIX <br /> P O BOX 2009, STOCKTON, CA 95201 J U N 2 8 1991 <br /> (209) 468-3447 ENVIRONMENTAL HEALTH <br /> 21MMIT EXPIRES. 1 YEAR PROM DATE ISSUED PERMIT/SERVICES <br /> I (Complete in Triplicate) <br /> Application In hereby mlade,to San Joaquin County for a permit to construct end/or install the work herein described. This <br /> I, application In made in conpliance with San Joaquin County Ordinar}c 449 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. { //��`//C// <br /> pi Job Address �S-3a (�—eajyj� TU. W tity Lot Size/Acreage <br /> It Owner's Name '^� dress _36-'� 0a � Imo" Phor9p <br /> Contractor ddress go d Cc>` ?_100LKCense No.J'_39'62-- Phone / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl <br /> PUMP INSTALLATIONSYSTEM REPAIR 3--� OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial Cl Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing , ji <br /> U Do <br /> Zastic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> ubfic Cl Other ❑ Delta Depth of Grout Seal Type of Grout . <br /> CI Irritation Ap rox, Depth 0 Eastern <br /> �� �'" N p este n /_Surface Seal Installed by Q <br /> Repair Work Done ice' Type of Pump' H,P. State Work Done Rr� <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: - Number of bedrooms <br /> Character of *oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypalMfg Capacity No. Compartments y <br /> PKG. TREATMENT PLT, C1 Method of Disposal <br /> Distance to nearest: Wel Foundation Property Line <br /> LEACHING LINE ❑ No, & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line <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 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 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 subcontracting 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 laws of California." r <br /> The applicant must call f r all required ' spections. Complete drawing on reverse side <br /> r G/ <br /> Signed Title: Date: . <br /> F R D ARTfNENT USE ONLY <br /> Application Accepted by <br /> Data <br /> Area <br /> Pit or Grout Inspection by Dats Final Inspection by Data / <br /> Additional Comments: j <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 AMOUNT DUE AMOUNT REMITTED CK # RECEIVED BY <br /> INFO CASH DATE <br /> jPERIAM.111'NO. <br /> EH 1324IREV.t/RsrEH ii.2a <br />