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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)465-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> it gEHLIT FIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> n <br /> Application is hereby maSan Joaquin County for a permit to construct and/or install the work herein described. s <br /> de to <br /> application is rade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �k Pe 2Z¢ 130.1 City Lot Size creege <br /> ss y� <br /> Job Add rea?a� <br /> T-z- Phone <br /> -f�OI <br /> 0vkner's Name rre:An n ✓Li Address <br /> 2-11 <br /> CaStF ctw ��_ -�_eF faa1-'.--JWdrxss y�2 $,;r "y ----License No. <?3c17/a� Phone t 7S' —Ll <br /> TYPE OF ELL/PUMP: NEW WELL <br /> --WELL REPLACEMENT Q i DESTRUCTION O out of 9ervlce We11 O <br /> OTHER O Idonitoring Well ❑ <br /> PUMP INSTALLATION O I I SYSTEM REPAIR ❑ r <br /> ' DISPLAL FLO. PROP. LINE _ <br /> DISTAN, E'TONEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> i- Ln FOUNDATION AGRICULTURE WELLWELL <br /> ,tet . �y.. <br /> ' IN{ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑'Inbustria! pen Bottom ❑ Manteca . Dia 101 Well Excavation r <br /> Type of Casin cTe.�L1 Specifications �rL <br /> 11'Domestic/Private ❑ Gravel Pack ❑ Tracy g Type of Grout p�"�r' 6+1 _ <br /> I'I Public f I.1 Other ^"fl Delta Depth of Grout Seal Sb ; "" - <br /> Itk <br /> ,,lgatlon Apprpx; Depth 1 I Eastern (Surface Seal Installed;by:iL , <br /> Repair Work Done ❑ Type of Pump H.P. V SYa[e Work Oona_ <br /> gealing'Nnteriel iDepth <br /> Well Destruction ❑ Well <br /> I iameter Filler !!tdrlal i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION l availablelw thin 200 leet.jed it public sewer is <br /> f ,Installation will serve: Residence_ Commercial_ Other <br /> iNumber o i Number of bedrooms <br /> -Ctiaraeter of soil to a depth o ' i r table depth <br /> ! Capacity No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg —� <br /> I � Method of Disposalt � <br /> Pill TREATMENT PLT.Cl 1 I <br /> k ! Distance to nearest: Well oundation } Property line <br /> LEACHING LINE ❑ No. 6 Length o - _ Total length/size .: <br /> FLYER OED ❑ JOistan nearest: Well E Foundation ' Property Line y- <br /> t F `� <br /> SEEPAGE PITS I Depth Sue Number <br /> 1 <br /> SUMPS LI Distance to nearest: Well I Foundation s Propeny Lina <br /> DISPOSAL PONDS O 1, <br /> t the work will done in accordanc4 with San Joaquin county ordinances, state <br /> I hereby certify that I have prepared this application and the <br /> bws;'an <br /> rules and regulations of the San Joaquin County <br /> Morita owner or licensed agent's signature certifies the following: "I ceriify that in the performance of the work for which this permit is issued, I shall nc <br /> uor's hiring or sub-contracting <br /> employ any person in such runner as to become subject to workmen's compensation laws of California."Contram atur <br /> certifip the following:employ <br /> 1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's comp.1, <br /> ton Laws of California." I; xI1J <br /> The applicant mus call for all squired nspactions. Complete drawing on reverse. <br /> I .• t 7JAi I Deta: <br /> Srer� wl� Title: <br /> 1 <br /> ` FOR DEPARTMENT USE ONLY <br /> 4 <br /> Data 12.. 1 _ q0 Area <br /> Application Accepted by w� 1 <br /> i <br /> Pit or Grout Impaction by f Date I 1 8' � Final Inspection by Data <br /> Addtbml Commenu: �LY%+-i, 9�3 34(.o Cl�_ C2� <br /> -ppyli'ce3t='geturil ccpiea to: San Joaquin County Public Health r <br /> 1 <br /> Services, fblviroamental Health Permit/Services <br /> 1601 Z. Hail Ave., P 0 Box 2009, Stock£co, CA 95201 <br /> ltw <br /> FEECk RECEIVED BY DATE r PERMIT'NO. <br /> INFOEllOUNT DUE AMOUNT REMITTED CASH <br /> ^ C o n .I (�(� (� is- ta kn 3-51 <br /> . EH 13.24 IREV.1/ear_ Q ' _ X-1 _ lY � _ ""'� - <br />