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� �. �• •F:. It <br /> N <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC IIEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> RQX DATE- ISSUE). <br /> (Complete iU Triplicate) <br /> Application is hereby nada,to San JOaquln County for a pertatt to construct and/or install the work herein described, This <br /> pp <br /> all stloa is W42 in coWlisnce with Ban Joaquin County Ordsr:enee Ho. 549 and 1862 and the Rulee and Regulations of flan <br /> Joaquin County Public Health Services. A <br /> Job Add,. <br /> �l F 4 j— �j L V r7 _ _ CnyG 11is.tctt- Lot Hite/Acreage / <br /> rLt-'�� 2Lt1 Pnons [ C•C' <br /> Owner's Nine YLk-S:,?��..�� <br /> • Centtactas 'r Addrelr2f=•-'�,/L1YQrtc"5'f i 17r� ice_License No5"r?7i.F�__FRane "_� L <br /> TYPE OF WELLIPUMP: NEW WELL 9 WELL REPLACEMENT IJ DESTRUCTION Ll put of Service well LI <br /> PUMP INSTALLATION 0 SYSTEM REPAIR (-] OTHER ❑ Monitoring Well <br /> DISTANCE TO N_EATIEST: SEPTIC TANK I SEWER LINES 50 DISPOSAL FLD. PROP.LINE --IL- <br /> FOUNDATION 20 AGRICULTURE WELL OTHER WELL PITSISUMPS a r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4-1- <br /> n <br /> rLl Industrial fJ Open Bottom l Manteca Dia.of Well Excsvation T� Die, of Well Cam H 4 d <br /> W Domestic/PINAIR KGravel Pack 13 Tracy Type of Casing ��C Spocitications <br /> 0 Public I:1 Other 0 Use Doplh of Grout Seal <br /> r,�oRF.*rf Type aI Grout i E<.r✓- <br /> C trugation ,SU Approu.Depth 0 Eastern Surface Soul Installed by <br /> Repair Work Dam L} Typo of Pump <br /> H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sooting Material Ii Depth_ <br /> Depth Piller Material&Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIRIAODITION LI DESTRUCTION 0 fNo septic system porinilled if public"war is <br /> available within 200 ful,1 <br /> i Inslakstiott will serve: Residence Commercial Other <br /> l Number of fivinq units. Number of bedrooms " <br /> j Chaiaclor of sok to a depth of 3 fest: Water table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity No.Compartments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE G1 No.b Length of linos Total length/size <br /> FILTER CEO ❑ Distance to ncamst: Well Foundation Property Line <br /> SEEPAGE PITS I i Depth Sire _ Number <br /> SUMPS LI Distance to nearest WMR Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> # I hsrsby comity that f have prepared this application and that the work will be done in aeeoldance with San Joaquin county 04nancss.stats taws.and <br /> t rules and rogutations of the Sen Joaquin County. <br /> Home owner 01 licensed agent's signatum certifies the 10owing:'9 cenify mat in the porfarmance of the work far which this permit is issued,I shall not <br /> amploy any pww in such manner as to become subject to workmen's componation Iowa of California."Contractors hiring or sub-contracting signature <br /> certlfias the following:"I Certify that in the performance of the work for which this permit is issued.I shall employ persons aubjecE to workmen's eartspena• <br /> tion laws of Wfornla.' — i <br /> i <br /> Themed~ t for uad pec ions.Complete drawing on raver"side. _ <br /> L <br /> Sinned �J TitW: �Cl/JSUc rA IJ bstr. /�{1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Arms <br /> . Pit or Grout inapection by Dole Final Inspection by - _ Date <br /> Wdlsbnal Cominorits: <br /> x <br /> /lpplteant Altura sell fopl,n tar BAN JOAQUIN COUNTY PUBLIC HEALTH BEAVICEB <br /> ENVIRONMENTAL HEALTH DIVISION PRANIT/8&RVI-'E9 <br /> 445 N SAN JOAQUIN. P O SOX 1009, STUCXTCtf, CA 06101 <br /> t M <br /> FitAMOUNT DUE AMCVNT REMITTED RECEIVED ay DATE PERMIT NO. <br /> INFO' CASH <br /> ll �E•i <br /> im <br /> y <br />