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APPLICATION FOR PERMIT <br /> ;:AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 93201 <br /> '209) 468-3447 <br /> PERMIT EICPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APpllcati0n is hereby madr to San :ca�uto County for a permit to construct and/or Install the work berain described. This <br /> +pplica%Ion is made in ccrowltance vith San Joaquin County Ordinance No. 549 and 1862 and the Pulse maid Regulatione of San <br /> :cvQuin County Public Health Service.. <br /> Jct)Address Aa W_L_ � ei City__ _ Lot Site/Aeresjq <br /> Owner's Nan'a _"� -�}IQJILM f Address r 0 ixxQ ' Phone <br /> ::'thdCtot_°/LEsd�LI�.-_-.`.r�. •f._ 4.••••31 Po fi.S.ri_`�-/--.. LSC enie No. one <br /> TYPE OF WELL/PUMP '{E'.4 v.ELL D WELL REPLACEMENT Pr DES"RUCTION Out of S4r3rii:e 411 <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR Cl OTHER D Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD._� PROP. LINE �/f.�f <br /> FCUNOATION — AGRICULTURE WELL OTHER WELL_ PITS/SUMPS * <br /> INTENOIED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPIE CIFICATI NS <br /> Ino trlei 00 frortom p Manteca Oia of Well Excavation Dia.of Wall Cs <br /> UOmislic/Private ravel Psck I.i Tracy Type of Caving_ SpeCdit/tons <br /> PubliO I I Other Z2 Dena Depth of Grout Seal T of Gr t <br /> ImUslion ' -_ Appro. Offtarn SwAit� el Installed <br /> OV <br /> nooso Work Done U T of Pump / H P. ✓ SItIf0work J&c <br /> / <br /> war DeftrrctbnWNI Diameter _sp_ Sealing Material A Depth / <br /> Depth 45M- ►Iller Material 6 Depth sa <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/AOOITION CT DESTRUCTION CJ (No septic system permitted it pNrblro tower is `� <br /> available within 200 INt.I C <br /> lnstenStion will NrW: Residence_ Comment Other <br /> Number of living units: Number of bedroom <br /> Character of soil to a depth of 7 feet: Water table depth r4) <br /> SEPTIC TANK O Type/Mfg C city No.Compartments , <br /> PKG. TREATMENT PLT,Q Method of Disposal <br /> Distance to nearest: Wan oundation Property Line <br /> LEACHING LINE L-I No. 6 Length of lines Total length/sire <br /> FILTER SED CI Distance to nfaest: Wen oundstion Property line L <br /> SEEPAGE PITS 11 Depth i» Number <br /> SUMPS LI Distance to nearest: well__ Founds on Property Line <br /> DISPOSAL PONDS Q <br /> I hereby fortify that I have prepared this appl-cation and that the work will Us done in accordance with Sen Joaquin county ordinances,state laws,and <br /> rules and regulst.ons of the San Joaquin County <br /> Home owner or d agents signature cart,(-es IM follow-ng ''I condo that in the performance of the work for which this permit is ruued,I shall not <br /> xmpi0y an son In a manner as to become subleci to workmen's compensation laws of California."Contractors hiring Or sub-contrac ling signature <br /> c.t free 4 fo":wing;"I C dy that in the parlormance of ter work for which Ihm permit is issued.I shall employ persons Subject to workman's cornponsa• <br /> On Ia of Calif rule." <br /> The a imam at cam r Om ng on r too. <br /> Spned -- ---- TIIIa:, _ Date: <br /> 4� to EPARTMENT USE ONLY <br /> �OC��Cadon AtcsOtad by �CAt�^�._1jyl�i 4 Date IS I Ana <br /> n I o.GroutlAspsetion by - Dat(i Final Impletion ai �� Daei <br /> Add,uonsl Comments: �� CC�7ii. _ <br /> A;plicaat - Return all coilSCAN JvOApUIN COUNTY PU LIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN. P O BOX 9009, STUCKTON, CA 06101 <br /> iy�tp AMOU4'ULr T—•M 4ONT ntM rT10 CASri n[ChVED ay OATI 0111M11 NO ``•\ <br />