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I <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC <br /> ENVIRONMENTAL HEALTH DI I <br /> 445 N SAN JOAQUIN, PHONE (20 <br /> P O WX 1009, STOCKTON, C O <br /> (Complete in Triglfca j} <br /> Application is hereby reads to Sea Joaquin County for a Permit to construct ao o} <br /> application Is made in compliance with San Joaquin County Ordinance Ho. 5k9 and ansa of San <br /> Joaquin County Public Realth Services. <br /> Job Address ' /Cfitr Lot 31 me/Acreage V <br /> Owner's Name �A 110s _1�+rwlr"►vti.1./Y Address �� + _... �� <br /> Phone <br /> to rl r q_ <br /> Contract W Address & a 7 License N*Az- z-Z G Phone 310gs/o <br /> TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑out of Service Vell <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Monito" Vall ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ��� SEWER LINES DISPOSAL FLP. PROP. LINE <br /> FOUNDATION AGRICVLTVRE WELL OTHER WELL PITS/SUMPS _ <br /> INTETIDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> !f 0 Industrial o Open Bottom 0 Manteca Dia. of Wall Excavation Dia, of Wen Casing <br /> C..] Domesticlprivate 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'1 Public n Other F1 pelta Depth of Grout Seal Type Of Grout <br /> I I Irrigation _Approx. Oepth 1 I Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> WON Destruction O Wats Diameter Seal.ittg Material i }Depth <br /> Depth Filler llaterlal A Depth <br />' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public eowar is <br /> available within 200 Ieet.1 <br /> InataNetion will Serve: Residenca Commercial_ Other - <br /> Number of living unite:—I— Number of ! <br /> Chw&CW of seal to a depth of 3 het: Watar table depth <br /> SEPTIC TANK -�4ype/ftAfq T ' r <br /> Capseity No. Compartments <br /> PKG. TREATMENT PLT,Cl / Method of Diosal <br /> , Distance to nearest: Wan Y f Foundation Property Line <br /> LEACHING LINe No.8 Langth of Ones O Total length/sire jr <br /> FITTER BED D Distance to riaarest: WaIE Foundation , Property line x _ <br /> fr <br /> SEEPAGE PITS Depth —SireNymber <br /> SUMPS L! Distance to nears": Wall Foundation n f- Property Lina• S t <br /> DISPOSAL PONDS • O <br /> I hereby cenify that I have pr"mmd this applicotipi and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and requlstkft of the San Joaquin Couatr <br /> Hon"owner or"censedt agant's signstufe certifies the following: "I certify that in the parlorrnanee of the worst for which this permit is issued. I shall not <br /> 06VIOy any person In such manner as to bacone wb*t to workman's compensation laws of California."Conifaelor's hiring or sub-contracting eignature <br /> ean5fies the fonowirlq:"1 mr*that in the performance of the work for which of CoNforthis permit is issued,I shall employ persona subject to workman's erimpanaa- <br /> lion lawn nla." <br /> E The sppliam All for a7�rce uif inspections. Compete drawing an reverse side. <br /> Signed 7Ir, Title: V.P Date: <br /> gy <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by y <br /> Dau Arg 7~-• <br /> r toe O"cmi.,l fin by Oeste 1/6-SK Final Inspection by r Date, <br /> AadltlorW Cemiriin� t �l,Cr <br /> App.licaet - Return all copies to: Mtn Joaquin County Public Healtb Services <br /> Environmental Health Permit/services ..14� <br /> J say N Baa Joaquing5, P ox 2008, 9ertn, OA O1 hh O <br /> O <br /> AMOUNT DUE AIVAOurrf it EtltTTEf} ffl-acv <br /> R1ECE1VED by DATE PERNt17'No. <br /> rH Ii•al i <br /> L� <br />