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+ APPLICATION FOR PERgI r1 0iNT:'-PLTBLICI1EALTHS'ERVICES <br /> TMi NTAL IIEALTII D'VTQION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH MAL PERMIT <br /> ENVIRONMENTAL HEALTH DIVIS <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> (209) 468-3447 CO ply <br /> PETIT EXPIRES 1 YEAR FROM DATE ISSUEQ <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County 1)l Health/Services. <br /> Job Address _ /7oSP irp� �tl, / City p Lot Site/Acreage <br /> Owner's Narriti JO in�2 U/•s' C�eonfY Address Phone <br /> 1l <br /> ConVac ror 2 u �KOc, L,..C. A d d I e s s.281S E /17YAr6tc- 5r• License No. $_/LI6g Phoneo YCr-87/ (� <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ C <br /> PUMP INSTAL TION C1SYSTEM REPAIR ❑ OTHER C1 Monitoring Well LG <br /> DISTANCE TO NEAREST: SEPTIC TANK /(nxi SEWER LINES 4/Ory DISPOSAL FLD>Z00 PROP. LINE /�000 fi <br /> FOUNDATION _16(_50 ' AGRICULTURE WELL7Sd_oOTHER WELD ' PITS/SUMPS >-ad ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n a. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> U Domasoc/Private 4 Gravel Pack C3Tracy Type of Casing PVL Specifications hy5M 'Fydo <br /> arAQ-V;rd - I.1 Other ❑ Delta Depth of Grout Seal R 3S/ Type of GroutC04cs„r/BOv:. 'lfh' <br /> ❑ Irnuation !OrAppro.. Depth ❑ Eastern Surface Seal Installed by_T C+ 11 <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Will Destruction ❑ Well Diameter Sealing Material L Depth <br /> Depth Piller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O flEPA1R lADDI TION Ll DESTRUCTION G (No septic system permitted it public sewer is <br /> N <br /> `\ available within 200 feet.) <br /> Instillation.will servo: Residence _ Commercial _ ONarT <br /> Number of living units: _ Number of bedrooms \\ <br /> Character of and to a depth of 3 feet: % \ Water table depth <br /> SEPTIC TANK ❑ T <br /> ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �. Method of Disposal <br /> Distance to nearer^,\ Well Foundation,, Property Line j <br /> LEACHING LINE ❑ No. 5 Length of lines \� Total length/size <br /> FILTER BED ❑\Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I De> th Sire Nu her I_ <br /> SUMPS LI Distance to nearest: Well Foundation Property Line �) <br /> DISPOSAL PONDS ❑ <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 and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance at the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workmen's compensat:on laws of California." Contractors hiring or sub-contracting signature <br /> tortillas 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." Wo.w PCHs' �v..�OCrt7�o'a' <br /> Theapptica(�x,?TiDV'4- N �re <br /> t call for all required inspections. Complete drawing on reverse <br /> Signed x 4 / <br /> ' f Title: ; "'a r cDate: 9 <br /> FOF3 DEPARTMENT USE ONLY � <br /> Application Accepted by ,`9y'L �%1 ! / LlL VQ.r�.(1{C�� I _ at* -:> Area <br /> Pit or Grout Inspection by '�t. CI �� Date I— �3 Final Inspection Dy , 'I�%'� "r"L Oats') " / <br /> i7 ' I 7( z <br /> ENVIRON1Ki �7 <br /> APPllcan S'Ae tuCIcopies 111" TNJOAQUIH,TH DIVISIO009ERSTOCKTONSV <br /> ICCA 8� C_ CC(/ <br /> INFO FEE AMOUNT DUE AMOUNT REMIT-TED CASH RECEIVED By DATE PERMIT NO. <br /> 05 �3 93 2^21 <br /> [N Im <br />