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APPLICATION FOR PERMIT <br /> SAA' 3AQUIN COUNTY PUBLIC HEALTH # 'RVICBS <br /> "'0' ENVIRONMENTAL HEALTH DIVIS <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447.2RRMT2:_rXE1= I YEAR PROM DATE ISSUED <br /> ; - <br /> (Complete in Triplicate) <br /> Application is hereby maps 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 Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address - 3 9 EhS l Tf�S�M 17 Atli VF <br /> City 1 � Lot Size/Acreage <br /> Owner's Name M00?F_ AErk mm , INS.__ Address ��IeG ST'f 84WTA, CA 9 314- Phone 27.1 <br /> /,Ia(cu c. , so 1 <br /> 3&&3 OME&C kar--I s✓fTE g <br /> Conitactor ddress /P�4AWC) COI(a'a0 ,¢ License No. �� Phorn <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT 7, DESTRUCTION Out of Service well u <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK U 9 IJSEWER LINES Q_M DISPOSAL FLD.. LIAJk,. PROP. LINE V'/'� <br /> FOUNDATION -11-4'-L- /i WELL--IV <br /> &A <br /> AGRICULTURE WELL OTHER WELPITS/SUMPS [e <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS h <br /> i� <br /> 0 Industrial O Open Bonom Msntaca Dia. of Well Excavation Dia. of Well Casing Z � <br /> U Domestic/Private Grave! Pack ❑ Tracy Type of Casing Pyc, Specifications <br /> Cl Public 1'1 Other ❑ Delta Depth of Grout Seal ri ffType of Grout II <br /> M Irrigation _Approx. Depth ❑ Eastern Surlacs Seal Installed by C <br /> Repair Work Done U Type of Pump H.P. State Work Done ) i <br /> Well Oestruction )Se Wall Diameter f JI!>4Set!(�Sealing Material i Depth to S/J <br /> Depth ---L Filler Material i Depth C-F_M6NT1/36A1T0VIrF_ 64tt � I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AOOITION CI DESTRUCTION G INo septic system permitted If public sower is <br /> available within 200 feet.) i <br /> Installation will "me: Residence— Commercial_ Other [ _ <br /> Number of living units: Number of bedrooms j� VP <br /> Character of soil to a deptn o/3 hat: KNo. <br /> r`a'bl pth �"� <br /> SEPTIC TANK ❑ Typeimig � <br /> I�acity 7Companmsrtts <br /> PKG, TREATMENT PLT. Cl Method of Disposal <br /> Distance to no est: II Fou dp?joPropenV Line J <br /> �J <br /> LEACHING LINE 0 No. 3 Length of lines ITotal lengtn/aizs <br /> FILTER BED n Distance to nearest- sl FoundationProperty Line <br /> SEEPAGE PITS 11 Depth „_Size Number <br /> SUMPS LI Distance to nearest: Wolf ApUndation Properly Line <br /> DISPOSAL PONDS ❑ <br /> 1 hareDV Canity that I have prepared This socircatron and that the worx wNl be done in accordance wrtn San Joaquin county ordinances. state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thrs 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 subcontracting signature <br /> candies the following: "I certify that IA the performance of the wort for which this permit is issued, t shall employ persons subject to workman a compensa- <br /> tion laws of California." <br /> The applicant m t call for a <br /> llPe�ctio�ns. Complete drawing on reverse side. <br /> Signed X._ L'N(,LY,"►G(1 Title: (✓�G�� I Date: I� � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by tDate S�� � Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 05201 L <br /> I FEE I AMOUNT OUE I AMOUNT REMITTED CASH I DATE OOO PERMIT NO. I <br /> INFO Cx a AECEwEO By <br /> I]-24 IJIEV <br /> . ,.� <br />