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nN <br /> sx <br /> i <br />-w' <br /> a <br /> APPLICATION FOR PERMIT e e <br /> SAN 3OAQUIX COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 2009, STOCUON, CA 95201 <br /> (209) 468- _-1A_-50 <br /> ATE lka= <br /> (Complete in Triplicate) <br /> Application in hereby Made to Ban JoaQuin county for a permit to construct and/or install the vark herein described. This <br /> Application <br /> Public is mI nSaotbianceiwith San Joaquin County Ordinance No. 544 and 19ti2 and the Ruled dad Regulations of San <br /> Joaquin <br /> d �• �_ Lot Siva/Acreag9 a <br /> ALj%771 City <br /> f Job Address <br /> Owner's Nirne �� SftFPL'/if3_ Address <br /> O G 0 Phone <br /> Contractor <br /> ddress 8,7 $6�L5. ' License No.�2{g oa Phone <br /> TYPE OF WELLlPUMP: ice Vall <br /> NEW WELL O WELL REPLACEMENT C3 DESTRUCTION ❑ Out or <br /> rsng Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C) 07HER�{ <br /> DISTANCE 70 NEAREST: SEPTIC TANK ��---- SEWER LINES �.--- DISPOSAL FLO. PROP. LIN " <br /> i <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL. -- PITSlSUMP_ _ <br /> 1tiTEN0E4 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D <br /> �-� Dia.of Weil Cssinq <br /> 0 Industrial f ❑Open Bottom u Manteca Die. of Wolt E>tuvalitira - —" Specifications <br /> CK Trac Type of Caeinq__ Pdl�-�--�-- <br /> is Domasticiplivan ❑Gravel Pack, Y of Grout . <br /> i [O Public �d 0 he,&WA14y5 ❑Dal to Depth of Grout Saal 1G ¢p K' Type <br /> U litigation L APPrort.Depth ❑ Eastern Surfacs Seal Ins:allsd Vy <br /> �9n� rre,ii� l�ildrla/ "E -- <br /> Ratsair Work Dora ( Type of Pump H.P. Stan Work Done r <br /> Wall OeltruotiOn ❑ We"Diameter <br /> SeaSi:rg Material 8 Depth <br /> Depth_ �d t _ Hllr+a Notarial i Depth <br /> TYPO OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITtON Cl DESTRUCTION CJ aWo vailatpetwSVIIithin 20+1 fawtitres�!public sewer is <br /> Installation vill servo: Residence_ Comenarclaf_ other <br /> Number of Going units: Number of bodimms <br /> Character of loll to a depth of 3 teat: Water table�apth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity �o.Compartments <br /> PKG.TREATMENT PLT.❑ Method of 011008,81 <br /> Distance to naormt-. Wen Foundation Property Lina_ <br /> LEACHING LINE 0 No.6 Length of lines Intel Iengthlu:w <br /> FILTER BED ❑ Distance to nearest: Wall Foundation_.�--- Property Line._��.. <br /> k <br /> SEEPAGE PITS 11 Depth ��Size .�-.� Numbor <br /> SUMPS LI Distar"to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> : I hereby certify that I have prepared this apOieatlon and that the work will be done in eccotdancs wish San Joaquin county ordinances, state taws,and <br /> rules And regulation$of the San JONUln Countir <br /> € Siomtl owno+or licensed agent's a)graturo cortifha the lottowing:"I certify that In the performance of the work for which this permit is issued.I shall not <br /> 1101 an person in such manner as to become subject t0 wollrman s compensation laws Of California."Contractor's hiring of sub-contracting signature <br /> emploa eartifies the following:"1 certify that in the p2darrnance of the work for which this permit is issued,I shall employ W raon■subject to workman's campenaa• <br /> tion laws of Colifomis:' - -The opplican t C for ed lnlpoetlons.COnipivta drawing on rovarw tide, !1 <br /> Title u' � ��� Dar. T' <br /> 8 Signed u�{ -*r o r+ � . <br /> i � <br /> FOR DEPARTMENT USE ONLY <br /> ILL, <br /> $� ate AreaL. <br /> Application Accep by <br /> t. <br /> Pit or Grout inepaEtion by Dela Final Inspection by. Dau <br /> ~.EddnlaMl Comtt+an�: <br /> �Appllcant - Return all copies tot SAN JOAQUIM COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PER[i1T/BERVIC83 <br /> 845 H SAN JOAQUIN, P 0 BOX 5009, STUCdTON' CA 86501 <br /> FEE AMOUNT DUE AMOVNT ltlMITTFO CASA C"V10 6Y 4ATE t+ERMIT N0. <br /> i INFO <br /> - , tot*24191Y.rreal - 4•-f.V� �'+j.vV ��/'� f -rf - 1 ) p+'C1'l v l <br /> j <br /> t <br />