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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> . ENVIRONNCENTAL HEALTH DIVISION <br /> P O BOX 2409, STOCHTON, CA. 95201 I <br /> (209) 466-3447 <br /> PFaMTT EXpIRBS 1 YEAR kRQX DATE IOSUSA <br /> (Complete in Triplicate) <br /> Application Is hereby made to Sab Joaquin County for a permit to construct and/or install the work herein deet bed. This <br /> application Is made in cosplisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regula ions of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> '2 !Or 9a& &0 City Lot Size/Acreage <br /> Owner's Name r Address Phone <br /> c[�l{fir_-Address d License No. $ _Phone <br /> . Cantractor�J..�_L'_��..- <br />„_ "•� TYP. f�.F.:V1?E:LLL?UMP; _ ,_ _NEW.WELL ❑. WELL...REPLACEMENT,[JDESTRUC7ION ❑ puL_of-Service we11 I-] <br /> PUMP INSTALLATION 0 SYSTEM REPAIR,❑ <br /> Monitoring Well <br /> OTHER O <br /> L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._._ <br /> INTENDED_USE R� J TYPE OF WELL PROBLEM AREA •CONSTRUCTION SPECIFICATIONS <br /> — <br /> M Industrial D Open Bottom "O Manteca Dia. of Well Excavation' Oia. of Well Casing <br /> U Domestic/Private _0,Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ri dther� _*I_ ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation __..Approa, Depth-~C]-Eastern^- .- `lZurface'Seal Installed by <br /> Repair Work Done Ll Type of Pump H.P. t State Work pone _ <br /> ° ! Sealing Material & Depth <br /> Well Destruction 1❑ Well Diamete . } i I <br /> Depth Filler Material i Depth' <br /> TYPE OF SEPTIC WORK: NEW INSTAL ' ON ff REPAIRlADDITION IZI DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Reiidence __ "Comnrorc ail_ Other <br /> E Number of living units:"' Numbrr of adraoms <br /> Character of;*oil to a depth 3 feel: ' il. 'Water table depth <br /> SEPTIC TANK �ype/Mfg) .. L Capacity 1�8 No. Gompartrrtents <br /> = Method of Dispo I <br /> PKG. TREATMENT PLT. ❑ /I s_ '. / <br /> Distance to nearest: 'Well'` L-2 Foundation. ^7 Propony Line <br /> r <br /> LEACHING LINE 4No &_Length of lines Tolal length/sus <br /> FILTER BED'j�_,, n'�-'.Distance.to nearest: Well 06 Foundation S:: Property Line J;6 <br /> SEEPAGE PITJ,! y epth !Sire __ s u <br /> SUMPS ri IDistance to nearest`:` Wali e , i „Foundation Property Litie:'. <br /> DISPOSAL PONDS <br /> I hereby certify that Lhave prepared this application and that the work-will'be done,in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulatio4'of the San Joarau`ln County( t r e, ,y. <br /> Home owner or licensed agent's signature certifies-the following: ' ,?r1ity that in-the performance of the work for which this permit is issued, I shall not <br /> employ any pe!son-in'such manner as to become subject-to workman's compensation laws of California." Contracto('s hiring or sub-contracting signature <br /> certifies thf following: "I certify that in the performance of the�woik for which this permit is issued, I shall employ persons subject to workman's compensa" <br /> 110A laws of California." <br /> C. <br /> ti')The applicant muit call for all requir inspections. Complete drawing on reverse side. <br /> Signed , !` Title:= IIsi G Date: �5_ 1,9L�Av_ <br /> dyFO DEPARTMENT USE ONLY <br /> a � <br /> Application Accepted by Date 5 _ <br /> it. r Grout Inspection to Date Final Inspection by Date <br /> f Additional Comments: ` /� 7« f�' DZ`N`` '� -h, <br /> qty rirf 9 �✓ ,2.1-r �G. �'ICY, <br /> 9/ <br /> Applicant - Retuxn all copies to: SAN,,��JOA UIN COUNTY PUBLIC HEALTH.SERVICES <br /> ENVARONMENTAL HEALTH;DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN,'P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK AiCHVED BY DATE PERMIT'N0, <br /> IINNFOg 1 CASH <br /> p �-7 <br /> + EN13.24IFIEV.1/Mal j { 1�43t'� �' l C•,1� d <br /> EM 1114.24 tp" LLL <br /> h <br />