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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 RECEIVED <br /> P 0 BOX 2009, STOCKTON, CA 95201 APR 2 1 1993 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY <br /> (Complete in Triplicate) PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Application is hereby Stade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressCityLot Size/Acreage �� <br /> Owner's Name AM A�E DUC4&49 W Address c34tyS• >�w�9�.sIM Cl�h on s � <br /> Contractor dress s• 449&�Qfi;nse No. Phon <br /> TYPE OF WELL/PUMP: NEW WELL-X_ WELL REPLACEMENT DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM IR ❑ OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK ff� SEWER LINES DISPOSAL FLD.I PROP. LINE <br /> FOUNDATION AGRICULTURE WELL""ter OTHER WELL PITS/SUMPS _ // <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (S1 w <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation` Dia. of Well Casing <br /> '.Domestic/Private *Wrovel Pack - '13-Tracy Type of Casing-, L Specifications ' <br /> Il Public fl Other n Delta Depth of Grout Seal x PZ Type of Grout <br /> I I Irrigation -.=Approx. Depth b"astern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ 4,5 <br /> Well Destruction O Well Diameter Sealing Material i Depth * <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION 1 I INo septic system permitted if public sower is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sop to a depth of 3 fest: Water table depth •� <br /> SEPTIC TANK O Typo/Mfg Capacity } No. Compartments n� <br /> PKG. TREATMENT PLT.O Method of Disposal' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest. Well Foundation Property Lina <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lin_e <br /> DISPOSAL PONDS O <br /> 1 hereby certify that 1 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 canities the following: "I certify that in the performance of the work for which this permit is issued, I shell 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appy at f sit r ad inspections. Complete drawing on r se side. <br /> Signed X Title: Date: 4CZ 4f ;6 PK <br /> FOR DEPARTMENT USE Y <br /> t. <br /> Application Accepted by Dato' q Area f <br /> Pit or Grou G Q 6ps <br /> nspoctlon by Data Final T�,3 ' nal Irrapection by` Data <br /> { <br /> Additional Comments: 1;12161� j -7 ,3 GsyG,O�lit.. <br /> Applicant - Return ad copies to: San Joaquin County Ablic Health Services '�t <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NOO. <br /> . EH13.71 111EV.t/N 5) <br /> EH 1478 1 V r <br />