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A,pPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC <br /> ENVIRONMENTAL HEALTH DI 1colk <br /> 445 N SAN JOAQUIN, PHONE (20 ) <br /> P 0 BO% 7'009, STOCSTON, C <br /> mnm <br /> (Complete in Triplica ) <br /> rw <br /> Application is hereby nada to fan Joaquin County for a permit to construct an o��7lrIF one of bans <br /> application <br /> ion is mae Public Nncompliaace viah Qaa Joaquin County ordinance No. 549 a <br /> Joaquin d <br /> Job Address W1,21 <br /> Q City�,�} Lot Else/Acreage <br /> Address <br /> Ownee Noma <br /> V I •`�'•'^ Phonti y — 77 <br /> 76 7 4 <br /> pD 1 " �� I-AZ Z G Phcrte 3b$ SIo <br /> Contract �" � Address_ r License No. <br /> TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT 11 DESTRUCTION ❑Out of Service Reil <br /> PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER O MonitorimS{leu (3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP, LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED US1: TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial El open Bottom ❑ Manteca Dia. of WON Excavation _�� Dia. of Wen Casing <br /> 0 Dornestio/private Ll Gravel Pack U Tracy Type of Calling- <br /> 11 <br /> 1'1 Public Cl otha, I fl Doha Depth of Grout Seat Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Dona U Type of Pump H.P._ Stats Work Dorsa_ r1 <br /> Well Demetion O Well Dhmstar Sealing Material i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADD17'ION I I DESTRUCTION I i iNo septic system permitted it public It is <br /> available within 200 leet.l <br /> Installation wdl arve: Reaidenca Cornmercial— Other <br /> j , <br /> Number of living unite:_L_ Number of S .� <br /> Chw w of sol to a depth of 3 Ian: Water table depth <br /> t <br /> SEPTIC TANK TypalMlg r Capacity <br /> No. Compartments <br /> PKG.TREATMENT PtT,Ll t� Method of EW tel <br /> Distance to nearest: We* Irl Foundation Property Line�T <br /> t <br /> LEACHING LINE No.&Length or line Total length/size X <br /> FILTER BED ❑ Distance to nearer: Well Foundation 4a -A— PropertyL r i+ <br /> It <br /> SEEPAGE PITS Depth 5" Nymber <br /> SUMPS LI Distance to neatest: Well�36 Foundation JA '0' Property Lina _ <br /> '• DISPOSAL PONDS • ❑ <br /> I hereby certify that I have prepared this application end that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the Son Joaquin County <br /> Home owner or fieensod agent's signature cartifiies the following: -I certify that in the performance of the work for which this Perm*is issued, 1 shalt not <br /> emofpy any person In such manner as to balelno subject to workman's compensation laws of CaNlornia."Contractor's hiring or su!}eontracting signature <br /> cortif`iao the folowft:'9 twtrtity,that in the partarmance of the work tar which this permit is issued,I aha%employ persons subject to workman's cornpsnsa• <br /> tion lays of California." <br /> The applicant N for WX insps.etions. Complete drawing an reverse side. <br /> Signed Title; "P Dau: <br /> FOR DEPARTMENT UBE ONLY <br /> Appbatlort Accepted by Data -2—hr J1 <br /> toor Gran Inspection by Date Find Inspection by r owl <br /> Addition alJ�entndrtti: t I#y <br /> Applicant - Return a1L copies to: Sam Joaquin County Public Health services <br /> Snviroamemtal Health Permit/ferric.. S�d7C) <br /> rJ 448 n San Joaquim, P aoo9, flkn, t7A 85 O1 <br /> 1 l INFO AMOUNT DUE At OUkT REMrrmn K RECEIVED SY DATE PERMIT No. <br /> . 6N t!to tltEv,r }'1�,v •� P61: <br /> EN 14� <br />