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i — 1 <br /> APPLICATION FOR PERMIT <br /> \ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �1 ENVIRONh NTAL HEALTH DIVISION <br /> � J 445 N SAN JOAQUIN, PHONE- (209)468-3420 <br /> P O BO% 2009, STOCKTON, CA 95201 <br /> r <br /> XW FROM 12ATE ISSUED <br /> (Complete in Triplicate) <br /> Apyllcstion is hereby Glade to &w Joaquin County for a.permit �to construct and/or Install the xork herein described. This <br /> applirstiaa is toad& in colepliance with San Josquin"County Ordinance Mo. 549 and 1862 and the Rules and regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address._-1 31713 Earal nn Ral 1 rite Rnarl City _E_rral nrz____ Lot Slee/Acreage 90 ar <br /> The Estate of <br /> Owner's Name .F,}I[rnrd Raj rhonh,irg Address 11035 Escal an Bal l ota Raod Phone838-2053 <br /> r Contractor Ri rhnrd-_Garner Address - 290171 3nlrpnRnad Oakda]*License No. A-R441 fifiB Phone847-3480 — <br /> =TYPE OF WELL/PUMP; NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> + PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER ❑ Nonitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._.r.._,.._. PROP. LINE l <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �, ? <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-) Industrial ❑ Open Bottom ❑ Manteca Dia"af Well Excavation - Dia. of Well Casing }{ <br /> I 1.1 Domostic/Privaste ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications <br /> PyrbliC n Oche► r1 Delta Depth of Grout Seal Type of Grout <br /> �.J <br /> ;r.l I Irrigation Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done L] Type of Pune H.P. _ State Work Dane <br /> Well Destruction ❑ Well Diarnetsr Healing Material i Death <br /> Depth Tiller Material air Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITION)()[ DESTRUCTION i 11No Septic system permitted if publiC sewer is <br /> available within 200 fsatJ <br /> Installation will serve: Residence__J_ Commercial_ Other <br /> Number of Nviny units: _I Number of bedrooms 2 <br /> i <br /> Chwacter of soil to a depth of 3 feet: h.ard pan Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg _ Capacity No. Compartment* <br /> #KG. TfIlEATMENT PLT.❑ Method of Disposal <br /> Dktance to nearest: Well Foundation_ Property Line <br /> LEACHING LINE ❑ No. &Length of lines Total length/size (\�` <br /> AFILTER 18E0 10 owl tonce to clearest; Well -Foundation Property Line <br /> SEEPAGE PITS kI Depth t Size_7 T x2 x23 t .. Number 1 <br /> SUMPS L1 .Distinow to nearest: Wall 120L-±-+, Foundation_5U2— Property Lina 75' <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, *tate laws, and�. <br /> rubs and regulations of the San Joaquin County <br /> Home owner of 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 1 <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hifing or sub-contracting 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 compense <br /> Non laws of California." <br /> The applicant st c f r all uir inspections. Complete drawing on reverse side. <br /> Signed Title: . owner/Carrier Construction Date: 3/22/93 <br /> OR DEPARTMENT USE ONLY l� <br /> Application Accepted by ° Date a A <br /> -Pis of Grout Inspection by Data Finat Inspection by <br /> .'Addhional Carnn+ertta: `'� <br /> Applicant - ,leturn all copies to. . .aao Joaquin County public 13ealth services <br /> Environmental Health Permit/services <br /> 445 N San Joaquin o7: 2009, Stkn, CA 85201. <br /> INF* AMFEE OUNT OUE AMOUNT REMITTED c,as RECEtWo By a TE PERMIT'NO. <br /> � -r.. r� C i <br />