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T <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ' PAYmENT <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> # P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED <br /> PERMIT EXPIRES 1 YEAR FROM D&TE ISSUED APR 2 3 1993 <br /> I (Complete in Triplicate) SAN JOAQUIN COUNTY <br /> PORLIC HEALTH SERviCFS ' <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the wx"*N *� j j ION i <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations o an <br /> Joaquin County Public Health Services. <br /> Job Address b uCit Lot Size/Acreage ! <br /> Owner's NameAddress P7,8 Phoned d <br /> Contractor -U�+_r�- L 'U Address2C�r� , 1/40 !,�_1 � �e No. 4CERZa� Phone W6 <br /> TYPE OF WELL/ MP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well Gl <br /> PUMP INSTALLATION O SYSTEM REPAIR L OTHER 0 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. f PROP. LINE ` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia.-of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑-Gravel Pack+T; ❑.Tracy -= T.ype of Casing Specifications <br /> I'I Public la Other i f1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern S rface Seal Installed by 'Z <br /> Repair Work Done 56 Type of Pump_,] _ H.P. -lez6; _ State Work Done <br /> Well Destruction 0 Well Diameter <br /> r Sealing Material i Depth <br /> Depth biller Material ; Depth [� <br /> O � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 240 fast.) <br /> Installation will serve: Residence_ Commercial— Other 3 (� <br /> Number of living units: Number of bedrooms <br /> Character of Will to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ y f Method of Disposal <br /> Distance to nearest:, well Foundation Property Line <br /> LEACHING LINE 0 No. S Length�of lines Total length/site <br /> FILTER BED 0 Distance.to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS 11 . Depth Sire _ Number <br /> SUMPS La Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS �0 - t .�. g "= - ,¢. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules end 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 sub-contracting signature <br /> certifies the following: "I cenify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant u all for ail required inspections. Complete drawing on r�{()erre side. <br /> Signed r Title: �L—! /Y�r� _ Date: <br /> R DEP NLY <br /> Application Accepted by---, Data A reA <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> t <br /> Additional Comments: p <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. , <br /> INFO <br /> EH 13-24 /f�y`� <br /> • EM t1- IRrN.iinbl { �L7/Orcy <br />