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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL <br /> OI <br /> _P O BOX 2009, STO HEALTH <br /> N, CA95201 <br /> (209) 468-3447 <br /> ESPIRES 1 XNA R 4ROM DATE_ % = t <br /> (Complete in Triplicate) %.VVP- y <br /> Application is hereby Wade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in tonpiLance with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations at San <br /> Joaquin CvADV Public Health services. <br /> Job Address6my2e r t: iCity Lot Size/Acreage Ae•ize - <br /> Ownsee Name f~ b �,��:b, �CiZZ__`Address '� Phons j f <br /> = •4-__L 1D -L_f I t i 2 ��z -Ph _ { <br /> • <br /> Contractor �[ N -�- -Addresa-.�� - •- � -*^• lie - <br /> TYPE OF WELI.0UMP: NEW WELQX WELL REPLACEMENT ❑ DESTRUCTION 0 out of Service Yell G <br /> PUMP INSTALLATION ? SYSTEM REPAIR ❑, OTHER p Nonitoring'Vell n <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES ' DISPOSAL FLD,-T-21PROP. LINT: V! <br /> FOUNDATION AGRICULTURE WELL . - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> n Industrial .Opan Bottom Q Menteca Oia. of Well Excov"I ft Dia. of Well Casing <br /> mostiolP►ivate p Gravel Pack C] Tracy Type of Casin Spet:Hicatjvns ....- <br /> Cl Public rn Other El Delia Depth of Grout Seal Ty of Grow �c <br /> 0 Irrigation K9512 Approx. Depth p Easlorn urfaco Seal Installed by Ualho_'VDR�l 1"A <br /> Repair Work Done L] Type of Pump H.P. - State Work 064 <br /> Well Destruction p Wall Diameter Seeling Material i Depth f <br /> IV Depth Tiller Material 8 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G INo septic system permitted it public sower is <br /> available within 200 feet.] <br /> t Installation trill serve: Residence— Commercial— Other <br /> '. Number of living units: Number of bedrooms <br /> Character of soN to a depth of 3 het: Water table depth <br /> SEPTIC TANK: 13 TypslMfg Capacity No.Compertmants r <br /> ' PKG. TREATMENT PLT.C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> t <br /> LEACHING LINE p No. 8 Length of lines Total length/sue i <br /> FILTER BED n Distance to nearest: Wall Foundation. Property Line <br /> i <br /> SEEPAGE PITS i l�Depth+ . Sirs S -. Number <br /> SUMPS •`Dislanca to nearest:-, Well Foundation Property Line - <br /> DISPOSAL PONDS . ❑ _ .L : . y -r <br /> I hereby certify that 1 hove prepared [his application and that the work will be done in accordince with San Joaquin county ordinances, state laws, and <br /> rules end regulations of Ihe:San Joaquin County <br /> Home owner or licensed agent's signature conifles the following: "I'eenify that in the performance of the Work for which this permit is issusd. I shall ho[ <br /> employ any porion in such manner as to become subjs"ct to workmen's compensation laws of CaRiornis."Contractors hiring or sub-contracting signature <br /> certifies the following:"I Certify that in the perlorounce of the work for which this permit to issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Colifomlel. <br /> The applicant must call for all required inspectlgns. Complete drawing on reverse side: <br /> Signe Tab: Date: <br /> FOR DEPARTMEW USE ONLY r� <br /> Application Accepted by r Data Area <br /> Pit or{trout Impaction by Date Final Inspection by ' DW-LL1 " <br /> ""._"AddNjoitil'Chrt171'iirits:'".. .� -� •�. ... .__ . �. . .-_,,. _ ... �- - _. - --...--nnn l <br /> Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC R8ALTIt SBRVICBS <br /> ENVIRONMENTAL HBALTH DIVI810M PERMIT/SERVICES <br /> 44$ N SAN JOAQUIN, P 0 BOX 2008, STCICKTON, CA 95201 <br /> K IF <br /> INF AMOUNT DUE AMOUNT REMIT-TED GASH RECEIVED By DATE PERMIT•µ0. <br /> . FMt7.7ilnay. ir S3 I�Q-p f4- - I' `t 1-d45 <br /> EN'i tla <br /> I -amu CZ4 Q <br />