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APPLrICATION FOR. PERIdIT <br /> SAN JOAQU I N COUNTY PUBLIC REAL'I'& SER V I CES. p�tr�■ <br /> ENVIRON-WENTAI, HEALTH DIVISION A4EjV r <br /> P O BOX 2008', STOCKTON, CA 95201 RECEIVE <br /> !- (209) 46873447 �' + <br /> JAN 1 9 1993. <br /> NC HAQUIN COUNTY <br /> (Complete in Triplicate) ENVIRONMENTAL <br /> S <br /> Application is hereby made to San Joaquin County fora MENTAL HEA1 T �7ryf <br /> appllCation is made in c permit to construct and/or install the work tterelri t�a'c'r11 This <br /> oabpliance vith San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �SD S j r <br /> Job Address �� Cil ��c<-F6y 0 /} <br /> y Lot 31 Le/ACreagE !{l��AG <br /> Owner's Name (� E� CQ� '`Addrass �u -- <br /> �'^ phone 442--Z 7O. <br /> //}} 7i <br /> CanlracloNs 252.3 Rsv.4e RGA. <br /> Address o License No. 470 PhoneT37 574 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C.7 DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ 1. SYSTEM'REPAIR C] OTHER5a1ionit nt swell U <br /> DISTANCE 70 NEAREST: SEPTIC TANK-26-01 J: 246F LINES Z�` DISPOSAL FLDPROP. LINE ,11: Y <br /> FOUNDATION S r AGRICULTURE WELL 60t ,_,_,• OTHER WELL _ PITS/SUMPS 6 <br /> INTENDED USE TYPE OF WELL PROSLEM"AREA CONSTRUCTION SPECIFICATIONS <br /> r.1 Industrial 0 Open Bottom ❑ Manteca Eia­7 Well Excavation Dia.'of Well Casing 640/1 C- <br /> Domeslic/Private ❑ Gravel Pack 0 Tracy Type of Casino �15 <br /> a Specifications <br /> D Public E�}Q.�Other , Q Dell3a Dr +ih Of Grout SeG_,(i -I Type of Grouir-111 e- &I"L <br /> Cj IrliUation 4� �App+o.. Depth ❑ EasiarnL <br /> 5urfaca Soul Instal;ud by�+2T.�Off"b r <br /> Repair Work Done U Type of Pump -IYIA _ _ j H,P. Stare Work Done <br /> Well Destruction ❑ Well Diameter _&/4 Sealing Material i 1)rpch <br /> Depth Yiller-katerlal i Depth <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION U (No septic system permitted if ptibtic suwer is <br /> • '� available within 200 feet.? - <br /> installation will serve: Residence Commsrcisl I, Other <br /> Number of living units: Number of bedrooms <br /> Character of IOU to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Typa/Mf <br /> 9 Capacity_ No. Companmenta <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation Propsny Lina <br /> LEACHING LINE L1 No. 8 Length of lines Total length/size <br /> FILTER BED C. Distance to nearest: Well Foundaiion Propsny Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L'I Distance to nearest; Well Foundation Proparly Line p <br /> DISPOSAL PONDS Cl <br /> 'I hefeby certify that I have prepared this application and that the work will be.clone in accordance with,San Joaquin county o+dinancas, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's signature certifies the following; "I Canify that in the porloemance of the work lot which this permit is issued, I shall not <br /> employ any person in such"neer as to become subject to workmen's compensation laws of California." Contractor's hiring or sub•contracling signature <br /> certifies the following: "I certify that in the performance 91 the work for which this permit is issued, I ihall employ parsons subject to workman's compensa• <br /> lion laws of Californla.' <br /> The applicant mu ea I r elf re aired inrpections. Complete drawing on reverse aide. <br /> w . <br /> Signed Title:" �d 5 Date:�pn• r4 9 <br /> !'FOR DEPARTMENT - <br /> Application Accepted by " _ f <br /> Date ea <br /> Pit or Growl I,napection by y <br /> Final Inspection by .Date !- <br /> Additional Comments: <br /> Applicant - Ratti=q all Copies to.. SAN JOAQUIN'COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONYENTAI, lfEA1.TH DIVISION PEHHIT/SERVICES o <br /> 445 N SAN JOgQUIN, p 0 110X 2008, STDCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K " <br /> INFO CASFI RECEIVED BY: DATE PERMIT'NO. <br /> EN I)74+7tLV.li4It Com® , v I - <br />