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APPn.LICATION —dA <br /> 7� IN COUNT# PUBLICSERVICES <br /> VIRONMENTAL HEALT t.M <br /> . SAN JOAQUIN, PHONE —3420 C' Qy <br /> P O BOX 2009, STt1CFTC? „ <br /> PERMIT IRES 1 YAR''' 5014- <br /> �� y <br /> AV (Complete in Triple toIVA <br /> A licat a hereby made to San Joaquin County for a permit to construct and/or in the work herein described. This <br /> Pp <br /> application 1s made in compliance with Ban Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Lot size/acreage <br /> .lob Address _ <br /> Cit '�'SyKAf 5'O`.fit ocr <br /> Owner's Name ���'�� ,qL STA27 _ Address <br /> R m Phone G"G <br /> 9,7CAj <br /> t. `f i7G <br /> FL© 7? <br /> ,� �.. 0-2) Address�_ E � <br /> ADJAAte — License No. —Phone <br /> Contractor <br /> ll <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl out o! Service Well ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR O <br /> OTHER C3 Monitoring Well C1 <br /> DISTANCE 70 NEAREST: SEPTIC TANK <br /> SEWER LINES— DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation <br /> Type of Casing_ Specifications <br /> (:1 Domestic/Private ❑ Gravel Pack L7 Tracy Type of Grout <br /> ;'3 Public Cl Other - i"1 Delta Depth of Grout Seal <br /> i i IrrigationApprox. Depth I I Eastern Surface Seal Installed by <br /> `~ <br /> of Pum H.P. � __..— State Work Done <br /> Repair Work Done U Type p Scaling Material i Depth <br /> Well Destruction O Well Diameter Filler tdaterial 1i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION -DESTRUCTION I I INo sod d it public saver is <br /> _ availab� <br /> Installation will serve: Residence Commercial, Gther, JAN 2 5 tom► <br /> Number of living units: Number of bedrooms 1a <br /> a depth of 3 feet: <br /> Character of soil to �" <br /> SEPTIC TANK a Type/Mfg _ � - Capacity <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well_ Foundation Property Lune <br /> LEACHING UNE Cl No. & Length of lines zz— Total length/size <br /> ftLTER BED C] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS II Depth ., Syr Size �X)o � Number / <br /> SUMPS Distance to nearest: Well Sn , Foundation l4 ' Prop" Lina <br /> DISPOSAL PONDS Q - -- <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 taws, 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 rttanner as to become subject to workmen's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify 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 must call for all required inspections. �onrplete drawing-on rsvane srde <br /> . Titre 1�--� Date: <br /> Signed X . <br /> ¢QR DEPARTMENT USE ONLY � �� Area �/,_ <br /> Application Accepted by - Data <br /> ' or Gr t inspection by r , r Date r�T Final In tion by Date <br /> � <br /> A ;' nor! Commantr ` <br /> Applicant - Re rn all copies to: San Joaquin County Public Health Services <br /> finvironmental Health Permit/Services d <br /> 445 N San Joaquin, P O Box 2009, Stk��52FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BPERMIT"NO. <br /> (�+ r INF //�y(� fl <br /> St- �Iffl <br /> EW t!-7e <br />