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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIEENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTM' CA 95201 <br /> (209) 468-3447 <br /> REMIT EXPIRES 1 YAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby Crede to San Joaquin County for a perait to construct end/or inataa.l the work herein described. This <br /> application is made in coa>pliance with San Joaquin County ordinance no. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Publics Health Services. Al-t7 <br /> Job Address CO / /t! ��G(,.�t'� T �F CaY .��� Lot Size/Acreage d /T <br /> Owners Name ��•�/� /t'/Y��1 Address tYJ/! Phone _3Ccrtiraclor <br /> Addressc��o?�f�lJ1� b �Y>�icense No. Phone — c' <br /> TYPE OF WELL/PUMP. NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well CI <br /> PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER Q Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK Jz(J i� SEWER LINES DISPOSAL FLO. PROP, LINE <br /> B FOUNDATION 3•� AGRICULTURE WELL ZOp/}OTHER WELL PITS/SUMPS &Li <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ci Industrial O Open Bottom O MantecaDia. of Well Excavation /7. Dia. of Well Cising y <br /> 1*Dom4;t1t:/Private .;Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> Public n Other - © Delta1. <br /> Depth of Grout Seat Type of Grout <br /> Irrigation -. 3eVgpprox.Depth D Eastern iurfacs Seal Installed by S. <br /> Repair Work-(?one ❑ Type of Pump H_P. V-7 - StAlW Work-Done <br /> Well Destruction O Well Diameter Sealing AsUrlal i Depth <br /> e Depth Piller Material i Depth - r. <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION D REPAIRIADDITION L, DESTRUCTION CJ INo :optic systam permitted if public sewer fs <br /> avail+tWe within 200 feet.) <br /> Installation win serve: Residence_% Commercial— Other S <br /> NwrA w,of Living units. Numbsr•of bedrooms f <br /> Charactor of soii'to a depth of 3 fast: _ Water table depth <br /> Dip <br /> SEPTIC TANK Y Q Type/Mfg ' ---- Capacity No. Compartrrwnts <br /> PKG. TREATMENT PLT,0 t --�.` _ <br /> �'��_ ) Method of Disposal <br /> Distancii to nearest: Well - Foundation Property Line I <br /> LEACHING LINE �❑ ""�1' w---^^ i—� ..� <br /> No. b Length of fines - Total length/size J <br /> FILTER BED O Distance to nearest: Well F urdalion Property Line <br /> SEEPAGE PITS 11 .Depth Sire - Number <br /> SUMPS p'1 l). Distance to nearest: —rWa rr Fovndaticn <br /> Property Line <br /> DISPOSAL PONDS ' ❑ ; i ± r� <br /> I nnaby certify that I have Prepared this application and that the woaFi'will ire al;w in accwith ith San Joaquin County <br /> cries and re+Julo6ons of the Son Joaquin County ordinances, state bws• and <br /> HorTe <br /> own*(or kcensed&-�ont's signature certifies the toilow•ng ''i terrify that in She performance of the work for which this permit is issued, I shah rP.t <br /> arnPloy any person m inch manner as to become subjec[10 worltman's cOm'VWsa:K,r+ lvwv of CafifOrnia.'"Contractors hiring or sub-contracting signaawa <br /> C"f4s;he 00A 4%"of tC,alii ,•I unity that'rr Cha performance of the work for which 1`114 pe.axtit is iiwad, I shall employ persons subject to workman's compeers&- <br /> TM appicant mkt5a +red iru drI Complete draw d ort+averse <br /> S+grted k "�Cli�` Title: r�G�'� �P � Oats: i zg <br /> %I -- <br /> FOR IREPARTMENT VSE ONLY <br /> Appl,cat or. Acc.ptad by 3�,-C\ ' <br /> Da7e Area <br /> Pit or/G!olf! <br /> Inspection by ate <br /> '✓�_.// finsf IrspectGon Ey��� Dote � <br /> Addnion,*Convr4, : <br /> A;yllcaat - Return all copies to: SAN JOAquIN COVN?Y ]PUBLIC ABALTH 9YAYICSS <br /> ENVIRONMENTAL HEALTH DIVISICar PEftIT/SERVICES <br /> 445 N SAH JOAQUIN, P 0 BLai 20CD9, S?Uf 1I:oN, CA 95201 <br /> FEE ?.4JLt1?Dili ~:K --- _ <br /> .NF0 ` AMOUNT P.EMiTTED ,, 3#.CfP:EC BY <br /> 4 ASM OA E PERMIT NO. <br /> - - r J <br />