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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC VICES <br /> ENVIRONMENTAL HEALTHJDVI445 N SAN JOAQUIN, PHONE9� 8-3420 (nP O BOX 2009, STOCKTON �vT EXPIRES 1 YE FR(Complete in Triplte),� u r a <br /> Application is hereby made to San Joaquin County for a permit to construct dhhll kk���ell a 11 the / T'Ttlis <br /> application it aside in compliance with Han Joaquin County Ordinance No. 549 the Rules and Regulations of San <br /> Joaquin County Public Health llervicee. <br /> ' Job Address �!;�Sn� I�� WR A) City rza)IJl C 11P Lot Size/Acreage 222 OF`S <br /> ' Owner's Name 6RAfJtt1Z7 CO2)t'R,UGT/Ate_ Address P12 2DA' A' -). STiY'Nir CA of��one ylrtn <br /> PL2—� _�P�_ 15�-5Sd/g1"9ya) lgbE2 //B <br /> Contractor /�'-S!�- 7S?i i� Address RX //�/ S,2"' J7� License No Perone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5 DESTRUCTION ❑ Out of Service Nell ❑ <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> lar <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /!)A' DISPOSAL FLD.�� PROP. LINE 'L( ' <br /> FOUNDATION /m' AGRICULTURE WELL l2zf— OTHER WELL ) Q PITS/SUMPS <br /> ' INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n <br /> Indwmal ❑ Open Bottom Cl Manteca Dia. of Well Excavation a " Dia. of Well Casing <br /> ❑ Dopestic/Private 'Gravel Pack Tracy Type of Casing 4Cw VV 9✓G Specifications <br /> ' 1'I Public C.1Other fl Delta Depth of Grout Seal / Type _ 1T <br /> yof Grout om <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal-Installed by��Y 40 -1-/ 34^r,aJ irc <br /> Repair Work Dona O Type of Pump H.P. State Work Done _ <br /> Weal Destruction O Wall Diameter Sealing Material a Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 1"1.) <br /> ' Installation will some: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 teat: Water table depth <br /> SEPTIC TANK- 0 Type/Mfg Capacity No. Compartments QN <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Rol to nsareal: Well Foundation Property Line <br /> LEACHING LINE ❑ No. A Length of lines Total length/sire <br /> FILTER BED O Distance toneurit: Faur�ation Property Line <br /> ' SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to ndation Progeny Line <br /> DISPOSAL PONDS ❑ <br /> ' I hereby certify that I haw 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 certifies 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 sub­centracting signature <br /> cenifes the following: "I cantly that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansti <br /> ' tion laws of Califbrnle." <br /> The applicant must fallO'i 1 r ed - pections. Complete drawing on reverse side. G� <br /> Signed%_/ Title:Kcn�2 tTA/'F//f2060� ex/Si Date: 1S-3 <br /> i�//i'�%lOFOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pk or Grout Inspection by Date Final Inspection by Date Z / <br /> Additional Comments: � n <br /> Applicant - Return all copies to: San Joaquin County Public Health Services r�JcO� ��N <br /> ' Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO ,/,,7 9 /� /CASH Q ,�yl <br /> 1M.IaEV.I/eel I. �f �V L �j 6� ��_ - V <br /> ..as <br />