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11 1 4% 0 APPLICATION e. PERMIT <br />9PICUIyEd <br />ENVIRONMENTAL <br />P 't BOX 2009,95201 <br />1 i 199Z (209) <br />!-_NV1P')NN�MEMALHEALTH (Complete its Triplicate) <br />ES <br />Application fierebya to San Joaquin County for a permit to construct and/or install the work herein described. This <br />application is made in ectapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />L.Aa/"6! i �.r� L ®i•f �F'^/'� n:._- `1A t%1��4e P -n4. A/ elr/®no•awba <br />/gttS „ as <br />- GA <br />Owner's Name ®YWQtii+i nL Address <br />IJr �_� 6 S>{'Oc.�C-f'py Phone 201 <br />GC y,, <br />/ 1 G- S'7 (2 <br />//G S&_d<gicense Phone - 7 <br />Contractor Address <br />No. j,. <br />TYPO OP WIWPUMP; NEW WELL 0 WELL REPLACEMENT n D STRUCTION C1 Ant of Servile* WaAA <br />V"b lf _2-2- PUMP INSTALLATION O <br />SYSTEM REPAIR O LYSIa C C✓ OTHER ;(Monitoring Well E7 <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �? S -b DISPOSAL FLDI,�_b PROP. LINE , ' <br />FOUNDATION AGRICULTURE WELL OTHER WELL > 4V PITS/SUMPS s E� <br />INTENDED USE TYPE OF WELL PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS ,' <br />Pvt <br />Cl Industrial O Open Bottom O Manteca <br />Dis, of Well Excavation Dia. of WON Casing Z <br />U Domestic/ Private i iGrovel Pack O Tracy <br />Type of Casing ZFf f ✓G� S4fj0 Specifications <br />Q Public Ct Other 0 Delta <br />Depth of Grout Seal ��" Type of Grout s f <br />G Irrigation _ Approx. Depth $lE stern <br />Surface Seal Installed by �� L fV't.t►rL <br />Repair Work Done U Type of Pump ► t✓ N.P, tate Worly Oo et <br />Well Destruction 0 Well Diameter Sealing <br />Material i Depth L fa b l o , <br />11;4 thr- Depth 02 ® tiller <br />material a D*peh rtaEaG. <br />TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br />available within 200 lest.) <br />Installation will serve: Residence _... Commercial _,._,. Other <br />Number of living units: Number of bedrooms <br />Character of toll to a depth of 3 feet: <br />Water table depth <br />SEPTIC TANK O Type/Mfg <br />Capacity No. Componments <br />PKG. TREATMENT PLT, 0 <br />Method of Disposal <br />Distance to nearest: Well <br />Foundation Property Line <br />LEACHING LINE L1 No. & Length of lines <br />Total length/size <br />FILTER BED L=1 Distance to nearest: Well <br />Foundation Property Line <br />SEEPAGE PITS 11 Depth Size <br />Number <br />SUMPS LI Distance to nearest: Well <br />Foundation Property Line <br />DISPOSAL PONDS O <br />1 <br />1 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 of the work for which this permit is issued, I shall not <br />employ any person In such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br />certifies 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." <br />The spplic mu t call for all require ins Ctions. Complete drawing on reverse side. <br />Signed Title:Dete:zx <br />FOR DEPARTMENT USE ONLY N� <br />Application Accepted by Date 7h/14 Area "� % <br />Pit or Grout inspection by _ Date Final Inspection by Data2ZI q2- <br />Additional Comments: <br />Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br />446 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON• CA 95201 <br />. Ex 13.24 IRV. r i e S <br />EH 114.29 <br />;,EE <br />-jt+ <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK <br />RECEIVED BY <br />DATE <br />PERMIT' NO. <br />W"1/ <br />:Z&L <br />