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Date <br />APOICititon Accepted by <br />Ph or Grout Irtipaction by <br />Additional Comments: <br />Data - 3 Area <br />tA. J. XJ/ie... Date <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC RRALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P 0 BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Applicatioo is hereby made .to San Joaquin County for a permit to construct and/or install the work herein described. This <br />application Is made in compliance with San Joaquin County Ordinance do. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />Job Address ./ 4- • "e "" R. ID Co -4 4619 Lot Size <br /> <br />Owner's Name A 2. A It j ec • Pirr-7.72 Address 5/47y/ 4" Phone <br />Contractor P4,41P 45- 44, az; ., Address 7 J. AD.4 /3, 4'1?-7" A-1/...47 License No .11--4-4.-74. Phone -,164--39 -// <br />TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well 0 <br />PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br />FOUNDATION . AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br />L-) Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation ()Lc of Well Casing <br />Cl Domestic/ Private 0 Gravel Pock 0 Tracy Type of Casing Specifications <br />CI Public Cl Other • fl Delta Depth of Grout Seal Type of Grout <br />1 1 irrigation - Approx. Depth 1 Eastern Surface Seel listened by <br />Rep& Work Done Cl Type of Pump H.P. State Work Done <br />Well Destruction 0 Well Diameter Sealing Materiel I Depth <br />Depth Piller fieterial I Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION,‹ REPAIR/ADDITION i I DESTRUCTION I I tNo septic system permitted it public sewer is <br />r'''' <br />available within 200 feet.) <br />Installation will serve: Residence Commercial Other <br />Number of living units L.._ Number of bedrooms -3 <br />chatector of sod to a depth of 3 feet. .S.dirtiPy e•-,Z-A V..1-4--"9-rn Water labia depth <br />SEPTIC TANK 0 Type/Mfg Pci-- 1.-- Copecit /6o f, No. Compartments 2-- <br />PKG. TREATMENT PLT, 0 12 Method of Disposal ap <br />Distance to nearest: Well 'Z." 6' Foundation We / Property Line LC/7 <br />LEACHING LINE CFI/ N. & Length of lines 3- - tee ' Total length/size / '2, C) ' <br />FILTER BED 0 Distance to nearest: Wed I 7 el ' tion 7 a ' Propeny Line <br />SEEPAGE PITS l'{ Depth 3-4-- ' Size 4 2- " Number 2- r SUMPS LI Distance to nearest: Weil he ' Foundation ke ' Property LineAi& <br />DISPOSAL PONDS 0 <br />' nsreoy Certify that I have prepared this application and that the work will be done in accordanc, 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 foltowing: comfy that in the performance of the work for Much this permit is issued, I shall not <br />employ any person in such manner es to become subasct to workman's compensation Laws of California.- Contrectors hiring or sub-contracting signature certifies the following: "I cortity that in the performance of the work for -which this permit is issued, I shell employ persons subject to workmen's comps/ma-lion laws of California." <br />The applicant must cad for all required inspections. Complete drawing on reverse side. <br />Signed X. Tide: <br />Date. - 2- - 9 1 <br />FOR DEPARTMENT USE ONLY <br />0 <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Perit/Serv jces <br />445 N Sao Joaquin, P 0 Box 2009, Stkn, CA 95201 <br />FEE <br />iNFO <br />SW <br />AMOUNT DUE AMOUNT REMITTED - eic I <br />CASH RECEIVED IV DATE PERMIT NO <br />kt'I tti'92 4) \Iti . 0 (-11--4:5 Rjm),3 Z -3-93 ct- int -1-3 EN 13-24 INEV. ),*A) <br />14.21