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APPLICATION FOR PER91T <br /> SAN JOAQUIN COUNTY PU13LIC REALTLI SERVICES. <br /> ENVIRONMENTAL HEALTH DIVISION PAYMENT <br /> P O BOX 2009', STOCKTON, CA 95201 aECeV[VLrD <br /> (209) 468--3447 N 19 1993 <br /> COUNTY <br /> (COmplete in Triplicate) ICHEA�THSERVICES <br /> ENVIRONMENTAL HEA T�I �/+�rn�� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herei $1:IRL1fSatLN This <br /> application is made in cowZi&nce vith san Joaquin County Ordinance No. 549 and 1$62 and the Rule# and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address S 00 Ci1y5MCKTQfJ Lot Size/Acreage - <br /> Owner's Name L N E ? Address E'GU �.n phone 461, Z 70 <br /> Conlracto4_21M9 399 SM&Avr Address 2523 ,t?ry o ReAd 4717 53 -x"76 <br /> License Pio. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION Q Out of Serylce Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR n OTHER Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK MSa1c 43kwr�vbs <br /> SEWER LINES ZW' DISPOSAL FLD r�A PROP. UNE %L <br /> FOUNDATION I Jr r AGRICULTURE WELL YZZ— OTHER WELLIYI� PITS/SUMPS 6�12 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation___$' ;F Dia, of Well Casing <br /> �Q Domestic/Private C) Gravel Pack C3Tracy Type of Casing—l�Q�-� Specifications <br /> Q Public X Other ❑ Delta O"Ill of GroutSeal �jy1 uGl` ,� 7 "Mf <br /> �ry f f <br /> ,t.� Type of GroutQn. <br /> U luioation f`2Appro>t. Depth ❑ Eastern Surface Seal Installed by rQ f'6r <br /> Repair Work Done U Type of Pump 1_ H.P, State Work Done _ <br /> Wall Destruction ❑ Well Diameter Sealing 14terial i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION 0 REPAIR/ADDITION L1 DESTRUCTION CI INo septic system permitted it public sower is <br /> available within 200 last.) <br /> Installation will serve: Residence _ COMMI(cial-,_ Other <br /> Number of living units: Number of bedrooms <br /> Character of ao11 to a depth of 3 feet: .Water table depth <br /> SEPTIC TANK. ❑ Typo/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 5 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Wall Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby cenily that I have prepared this application and that the work wi{I be done in accurdanca with San Joaquin county ordinances, state laws, and <br /> rules and re9ulalions of the San Joaquin County <br /> Home owner or licensed agent's signature conifies the following: "I cenily that in the pariormance 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 C&lilOmia." Contractor's hiring or subcontracting signature <br /> certifies the following:­I certify that in the performance of the work for which this permit is issued, f shall employ Dotson&subject to workman's compenia- <br /> tion laws of California," <br /> The applicant mu ca I. r all re uired inspections. Complete drawing on ravers& side, <br /> Signed <br /> Title.- Ca S <br /> Date:Jd n._r4_ /943 <br /> FOR DEPARTMENT <br /> Application Accepted by <br /> Date 7� <br /> ea <br /> Pit or Grout inspection by Final Inspection by <br /> Additional Comments: <br /> APP11ce"ot -Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERWIT/SERVICES <br /> 443 N SAN JOAQUIN, P 0 0OX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K Vito ��j <br /> INFO CASH RECEIVED ay DATE <br /> EEHH:S.+.7�4 ltEV, �� <br /> "'A" NO <br /> e , <br />