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T <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> + <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 t` "s� �� <br /> P O BOX 2009, STOCKTON, CA 95201 V D <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 1992 <br /> (Complete in Triplicate) ` , <br /> s <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the This <br /> application is Sade is compliance with Ban Joaqui7", <br /> ty Ordinance No. 51+9 and 1862 and the Rules and Regulations o! San <br /> Joaquin County Publi Heal7P� <br /> rvices. , <br /> xJob Address 7 14ld City Z!{ l L` Lot Size/Acreage l ACI`1_4_11> <br /> "Owner's Name l � � / `= Address hon <br /> Contracts L14Y-4�r% 4``� 1 fess ,i,r Ii Licens o. Phone /f 3 �K -31 w'f <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLA EMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATI SYSTEM REPAIR O ER O Monitoring Well O <br /> DISTANCE D NEAREST: SEPTIC TANK _,�e SEWER LINES �_ DISPOSAL FLD. PROP. LINE-_2-5FOUNDATION % _ AGRICULTURE WELL r OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> C7 Industrial O Open Bottom O Manteca Dia. of Well Exeavat;cn J�3 Dia. of Well C 'n <br /> .Qomsatic/Private `Gravel Pack � L7 Tracy Type of Casing , � �r��'t"IIl Specifications <br /> 11 Public ff,' Cl 9ther n Delta Depth of Grout Seal Type of Gro ►�'� 1V <br /> I I Irrigation Y �d Approx. th ,11.Eas ttt - ..y_., al Installed by �` <br /> Repair Work Done : U Type of Pump' ! 4ekt H.P. t ork Done <br /> Well Destruction i ❑ Well Diameter _ Sealing MlaterialE i Depth <br /> Depth-- ^— Filler Material Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION!I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Comm4rcial_ Other <br /> Number of living units: Number of booms <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 <br /> LEACHING LINE Ll No. b Length of lines Totals length/size <br /> FILTER BED PU- .-Distance to neuesi Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire ' Nu�ber <br /> SUMPS CI Distance to nearest: Well F - Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 h certify that I have prepared this application and that the work will be done in accordailligjwith San Joaquin county ordinances, state laws, and <br /> s and repulatiora 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 toMowing:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to work n's compensa <br /> tion all orni <br /> a st for r tion Co a drawing averse aid .e� <br /> -sp U Title: ���'� 'fCs��✓' Date: ?Z <br /> / I <br /> FQR DEPARTMENT USE ONLY Q, 1f7 <br /> Application Accepted by + Date_ �✓ �� Area 0� ` <br /> Pit rout <br /> Gtion byAO Date tt f� inal Inspection by Date �f <br /> Additional Comments: L, <br /> A ' (Wr-) 9yg-7o 69 <br /> Applicant —Return all copies to: San Joaquin ounty Public Health Services <br /> _ Environmental Health Permit/Services -I--- <br /> 445 <br /> - 3051/"�,fy20�/ <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> i <br /> FEE <br /> IN 0� AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y 0 TE PE MIT'NO. <br /> . EN M24(REV.1/a 51 �N <br /> EH 14.26 f QG® e� <br />