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i APPLICATION FOR PERMIT I <br /> SAN JOAQUIN COUNTY PUBtIC, EEALI'H SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX- 2009, STOCKtON , - CA-9520"1 <br /> (209) '468-.34ZU _.� €� rel; rah r.jr <br /> R N <br /> (Complete in Triplicate) <br /> .Spplicatlon Le hereby made to San Joaquin County for a permit to construeand/or install the work herein described. This <br /> +,Ppllcation Is made in compliance with Ban Joaquin County Ordinans <br /> Jc-&quin County Public Health Seryieea. cc NO. 51+9 and 1862 and the fiu1 and S <br /> Regvlatl'one of un <br /> Jot) A d a s a a s City Lot-Size/Acreage <br /> Owner's .Name 4,11CILICA Q,,2 �j$ <br /> Address�VAX �T��� / Pnono 4,4 ^577/ I <br /> Contractor .�r _ �O _ <br /> Address e o /G qrF <br /> _— License No./y(e 68 pnonz 73L3233 <br /> - <br /> TYPE OF WELL/PUMP: NEW WELL, ❑ WELL REPLACEMENT [I DESTRUCTION G Out or Service Well ❑ <br /> PUMP INSTALLATION 0 :. SYSTEM REPAIR C; OTHER r SOMo�itoring `Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ���r probers <br /> -acts SEWER LINES /4 .' DISPOSAL FLD.1_✓1W PROP. LINE _.5 <br /> FOUNDATION - S—�. AGRICULTURE WELL OTHER WELL /D PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO$LEMAREA CONSTRUCTION SPECIFICATIONS E <br /> (l Intluslrisl 0 Open Bottom 0 Manteca Dia, of Well Excavation .�1• rl <br /> Dia. of Well Casing .LXCZ— <br /> Dome:sic/Private Cl Gravel Pack 0 Tracy Type of Casingd G <br /> 5pecilicauons <br /> (. Public } - <br /> lllrOthar ❑ Delia Depth of Grout Seal ��__fi�� Type of Grout / <br /> oL.Approx. Depth ' C1.Eastern Surface SOO instaflad by <br /> Reoair Wort Done U Type of Pump- H.P. . State.work Done <br /> Wolf Deruuction ❑ Well Diameter Scaling Yateri►l Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION C1 DESTRUCTION G IN septic system permitted if public sdwer is <br /> available within 200 loot.) <br /> Intttgalion will wive: Residence _ Commercial Other + :+ <br /> .Number Of living units: Number of bedrooms <br /> Chrracter of soil to a depth of 3 foot: ' <br /> -----Water table depth _ <br /> SEPTIC TANK ❑ Typa/Mfg Ca acity,�_^�•`_ <br /> P _ `:No. Compertn erns <br /> PKG. TREATMENT PIT, ❑ <br /> Method ol,Diaposal <br /> Distance to nearest: Well foundation Property Linn <br /> LEACHING LINE 0 No. 8 Length of lines � Total lenpthlsiie <br /> FlLTEA SED t,6 Distance to nearest: Wall _Foundation r, <br /> Property Line <br /> SEEPAGE PITS <br /> 11 Depth Sire k _ Number f <br /> SUMPS Lt Distance to nearest, 'Well Found <br /> at;on Property Lina <br /> DISPOSAL PONDS ❑ <br /> ! neraby certify that I have prepared this application and that the work will be done in acccroanca with San Joaquin County ordinances, stata laws. ant? <br /> ruler and regulatnons of the San Joaquin County _ <br /> mome owner or licensed agent's signature carlifies the following: "t Certify that in the yunorrnanca of ma work for which this permit is issued. I shaft not <br /> emplpy any parson in tach manner as 10 become subject to workman's Compensation taws of f'9litorlt;B.•' Contractor's hirin or sub•conubttin <br /> certi"l Ihs following: "I cenify that in the fporformance Of the worst for which this Permit is issued, I shall em to g g'srpnature <br /> tion laws of Caliloinla." p y parsons sv bjacs to workman's Compania• <br /> Tho epplit and I ca r all re utred intp"11011a. Complete drawing on reverse side. <br /> 5ignatf Title: //1 ! �!l Zl 1S <br /> .Date: <br /> R DEPARTMENT USE ONLY LL y <br /> w41 <br /> APPlication cCepled by <br /> Pit or Groul Impaction by Date i - <br /> . Final lncpection by Dase _ <br /> Additional Comments: - - <br /> •�Ppt-:c�t - Return all coplaa tol SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION.PERMIT/3E11V10ES <br /> 445 H SAN`JOAQUIN, P O BOR 2008, STOCKTON. 'CA 95201 k x <br /> FEE <br /> INFO AMOUNT DUCE AMOUNT REMITTED AECEtYED 8v <br /> __LAS 11 DATE - PERMIT'NO. <br />