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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Ab P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 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 Address City f:MLmf,) Lot size/Acreage <br /> Owner's Name �u� CJI'-L1 S Address w�J JT Phone 2- 2 2. <br /> Contractor_�_,�/���� • <br /> _Address .Si1Ar%i: oi<:4 95'$3Y License No. Phon 0 9�3 33ec' <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION O gut of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER rr r W*1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1771 Industrial O Open Bottom O Manteca Dia, of Well Excavation Dia. of Well Casing <br /> CJ Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> M Public Cl Other O Delta Depth of Grout Seal Type of Grout Amir«jaa <br /> G Irrigation Approx. Depth ❑ Easter Surface Seal Installed by <br /> Repair Work Done L3 /Type of Pump ate Work Done <br /> Well Destruction O/ Wall Diameter seali D h { ,� <br /> Depth F ler Materia. i Dep <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAI / W� 9SffI�(Rt�l�I optic system permitted if public sewer is 01 <br /> rf �rf1�rJJ'' rthin 200 feet.) <br /> ��k V do let d Spected <br /> Installation will serve: Residence� Commercial_ then. �r lis <br /> Number of living units: Number of bedrooms ��� " ;, .sql l� lth DI 1 <br /> Character of soil to a depth of 3 feet: --+ry ter table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Q Method of Disposal `�•-') <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> ' el _ /93 <br /> Signed Title: �'�"�//-'ayylq.'+'+�ek SArnf'c�:�k: Date: ..,�l� <br /> ' .FOR DEPARTMENT USE ONLY�Hbj <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: s L Sar.5eb. <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTi3l HLIC,HEALTH SERVICES <br /> N SAN JOAQUIN, g, ]3�t11IT/SE#if/ICrE$ <br /> ENVIRONMENTAL HEAR VI <br /> 9ION Pq <br /> K 0 Tt t Q 5 k <br /> OX 2 09 KT f A 83201 <br /> c. rI <br /> FEE <br /> 00 INFO <br /> AM1bGY1JO tlfkl t":' t S r adm <br /> }//}'']]�1 „,yam <br /> EH122l1REVrlin,yi ,. n ' 7f/� /. 10,� <br /> EH;62e l <br /> ,r <br />