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r <br /> APPLICATION FOR PERMIT <br /> 4r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 198DED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coegrliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �r n C-7 <br /> Job Address3T- 1��L�}2A�� - _ Cit Lot�,Si�ze/AAcrreemge t <br /> Owner's Name&—,W-4 2i �. ALo, Address-2a o, ' t 3" S�Phone J-7-7-41121 <br /> Contraclo Address 1V License No..sr+7a/s 3 Phone -dS S/6 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION L9' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C) <br /> DISTANCE TO !NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Cssin9, <br /> 11�+t6mestic/Private -B-Gravel Pack El Tracy Type of Casing.f..ySpecifications <br /> 11 Public fa Other n Delta Depth of Grout Seat �t Type of Grout ? <br /> I I laigation —.Approx. Depth �� � tern SurfaceSoulInstalled by da.1 <br /> Repair Work Done 0 Type of Pump AZL=J� H.P. 4&: J g�� - State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material i Depth [ ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sews( is <br /> available within 200 feet.) � <br /> Installation will serve: Residence_ Commercial T Other 1�\ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line PAVAA CCT <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lin t U 2 6 J993 <br /> SANJOAnl IInt rru NT-Y <br /> SEEPAGE PITS I I Depth Sire Number PUBLIC HE ICES <br /> SUMPS LI Distance to nearest: Well Foundation Prope r ENTAL HEALTH DIVISION <br /> DISPOSAL PONDS 0 <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 sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's componss- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: / Date: <br /> R DEPAR <br /> Application Accepted by are Ar <br /> Pit or Grout Inspection by Date <br /> Date Final Inspection by Dat11 <br /> L-�� <br /> Additional Commentsf7rsrr�Ef�.!•,22�t ��_ r -- --- -- <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> gEE AMOUNT DUEWMITTED CAR CEIVED SY O TE PERMIT'NO. <br /> r;N 5476 C/- <br />