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L <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUIED. <br /> (Complete in Triplicate) <br /> A _ <br /> Application is hereby made to San Joaquin County .tof'a. permit to construct and/or install the work herein described. This <br /> F application is made in compliance with San Joaqufn County Ordinance 80. 5 4 and 1862 and the Rules and Regulations of San <br /> r':: <br /> Joaquin County Public Health Services. �. <br /> �� � Fi , , - y <br /> Job Address Cit �SZ � Lot Size/Acreage... <br /> Owner's Name Address t;4 to` r 1,;7 247 M7-Vo Phone 0 <br /> }I <br /> l � /�t Address LQ> u i'76 7.��yDa7$2 2� Phoned <br /> Contractor License No. <br /> TYPE OF WELL/PUMP: III. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> LINTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS W <br /> 0 Industrial �­❑ Open Bottom -❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f I'I Public 1-1 Other_ fl Delta Depth of Grout Seal Type of Grout <br /> r I I Irrigation I1 .Approx'Depth I I Es-stem Surface Seal Installed by <br /> 1 Repair Work Done ❑ Type of Pump H.P. Stara Work pone <br /> Depth <br /> tDe <br /> Scaling Material Ii p <br /> t <br /> Well Destruction ❑ Wel Diameter SeaI <br /> Depth ller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR ADDITION I I DESTRUCTION I l INo septic system permitted if public sewerli <br /> �� f ' available within 200 feet.) <br /> Installation will serve: RealL.2-L_Commercial— Other <br /> .Number of Irving units: �,=-Number of bedrooms -- ---��-- <br /> Character of soil to a depth;k f 3 feet: ^� Water table depth d <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: WeAL LA Foundation Property Line <br /> LEACHING LINE "No. 6 Length of lines Total length/size �- <br /> FILTER BED Cl 4Dlistance to nearest. Well Foundation _ Property Line <br /> SEEPAGE PITS lq'''pepth Size — Number ! <br /> SUMPS LI 4Distance to nearest: ""'Well-' Foundation�. Property Line - <br /> DISPOSAL PONDS ��'❑ k ""t It { J <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 Sin 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 meaner as to become subject to workmari's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fdkrMng:-"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."., �I <br /> The applicant mus call for all required inspections. Complete drawing on reverse :ids. <br /> Signed Title: Date: <br /> 1 - 93 <br /> ' s ' <br /> r + FOR DEPARTMENT USE ONLY Z <br /> ' 4 <br /> Application Accepted by A Date 'r ew Area <br /> Pit or Inspection by �M Dat Final Inspection by Data <br /> Additional Comments: I�. - r .eJ_ �� -vl�� �r��� n <br /> Applicant - Returnj l�ll copies to: San Joaquin County Public Health Services ✓ " `^' AA-c^4--k <br /> ' Environmental•Health Permit/Services <br /> 445 N San•Joaquin, P'0 Box.-2009, Stkn, CA 95201 r�1` <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> r <br /> EK 1131(REV.N"51 <br /> Ip. - 7%. 1x <br />