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APPLICATION FOR PERMIT <br /> SAN JOAQUIN.=COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCgTON, CA 95201I R Q .0 <br /> T (209) 468--344? <br /> 1 76 0 /y / L�4 A-V' PERMIT E%P1199,11, YEAR OROM DATE ISSUED <br /> / (Complete in Triplicate) <br /> /40 <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 r in erNo. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County�Public Health Sery ,r:l . <br /> Job Address -;IV e Lot Size/Acreage 9 C . <br /> Owner's Name F,G It �c r'1/JJg.� Address r G1 d tQILJ-55aZ,37 Phone 4F711 f <br /> ContractoriER;9�� <br /> Address License h€o. o�-�J ta� Phone <br /> TYPE OF WELL/PUMP: LurR NE EL WELL REPLACEMENT C_l DESTRUCTION ❑ out of Service Well 0 <br /> PUMP I STALVAT 0�; SYSTEM REPAIR ❑ OTHER O <br /> Monitoring Well 0 ! <br /> DISTANCE TO NEAREST: SEPTIC TANK- Inn SEWER LINES d DISPOSAL FLD,�s1 _ PROP. LINE <br /> q g� 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial XOpen Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type=of Casing,eT=jr l- Specifications <br /> M Public C1 Other 0 Delta Depth of Grout Seal 1013r Type of_Grout c <br /> CI Irrigation Apprax+Depth ❑ Eastern Surface Seal Installed by LL �-& <br /> Repair Work Done U Type of Pump;-1' b- - H.P. State Work Done_ <br /> Wall Destruction• O Wait Diameter$ Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF .SEPTIC WORK: .NEW INSTALLATION 0 REPAIR/ADDITION C I DESTRUCTION G (No septic system permitted N public sewer is <br /> ,.,tom-` available within 200 feet.) �+ <br /> Installation will serve: Residence __ Commercial_ Other r <br /> Number of living units: Number of bedrooms ' <br /> Character of soil io a depth of 3 feet: Water table depth <br /> SEPTIC TANK. Ip -Type/Mfg Capacity No. Compartments <br /> PKC. TREATMENT PLT. 0 Method of Disposal <br /> } Distance to nearest: Well Foundation Properly Line .. y <br /> I <br /> LEACHING LINE L1 No. A Length of lines Total length/eize� <br /> FILTER BED ❑ Distance tot nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth f Sire Number <br /> SUMPS Cl Distance to'nearest: Well Foundation Property Line 1 <br /> DISPOSAL PONDS 0 <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 cenifies 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 A�usicor all r quired inslActions. Complete drawing on (averse_iide. <br /> Signed x1 _ Title: L�te2a11�IJG ! cs sZ Date: <br /> =R=RTMENT USE ONLY 12, <br /> Application Accepted by Dat s "�� Area <br /> Pit or rou Inspection by Date Final Inspection <br /> Pit Orem), Ins by Date r <br /> Additional Comments: -[L�s l�Z 7 <br /> Applicant - Return s11 copies to: SAN JOAQUI1 COUNTY PUBLIC HEALTH SERVICES T <br /> }ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 1445 N SAN JOAQUIN, P O BOX 2049, STOCXTON, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> a 1�-21 iREV. <br /> EH 1/K51 J � .o-D D34 �"' {^ I u {0 . <br /> EH',1.=e <br /> °(u-29 00 T i <br />