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1 <br /> i APPLICATION FOR PERMIT <br /> 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION f <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> gpRES IYEAR FR9DT <br /> (Complete in Triplicate) <br /> in <br /> Application is hereby made to San Joaquin County foCounte ordinanceto nNoru549and/or <br /> 1862 and theeRules and Regulationsdof SanThis <br /> pp <br /> application is made in compliance with San Joaquin Y <br /> Joaquin County Public Health Services. lylariteca Lot Size/Acreage 1.acres <br /> 9000E. Lath Rd. City <br /> rtecJob Address 823-7754 I <br /> I Address 1i ria Phone1. <br /> Owner's Name �Ohn AllEffin 545-1185 <br />` HemingS BrOs. r Address 3525 P�la�dle Ave. License No.�13 11 11 Phone <br /> i Contractor WELL REPLACEMENT CJ DESTAUC7ION Ou11t of Service Well ❑ <br /> I NEW WELL ❑ OTHER 11Monitoring Well <br /> I TYPE OF WELLIPUMP: ' ; SYSTEM REPAIR <br /> PUMP INSTALLATION ❑ ❑ <br /> SEWER LINES _�.---- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _�___�— OTHER WELL PITS/SUMPS <br /> FOUNDATiON _ AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM� EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Welt Casing <br /> Dia. of Well Excavation <br /> n Industrial ❑ Open Bottom C1 Manteca tion Specifications - <br /> ❑ Tracy Type of Casing <br /> F7 DomesticIPrivate ❑ Gravel Pack Type of Grout <br /> la Other F-1 Delta Depth of Grout Seal <br /> U1 Public Surface Seul Installed by <br /> I I Irrigation Approx. Depth I I Eastern State Work.Done1.0 — <br /> H.P. <br /> Repair Work Done. LJ Type of Pump— Sealing Material & Depth ~^t �---�— <br /> Well Destruction Well Diameter/—I ? Depth <br /> Depth <br /> - 111er Material & Dep - - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 4 I <br /> 7E—PAI UADOITiO17.7. DESTRUCTION I 1 aaailabPesetrw Thin 200 withstem in <br /> if public sewer is <br /> Installation will serve: 'Residence Commercial— Other s A <br /> ry <br /> Number of living units: Number of bedrooms �c° � :Sr, <br /> -Water table depth <br /> Character of;toil.to s depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK. EJ -Type/ g Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> — <br /> Distance to nearest: Well <br /> A <br /> Total length/size <br /> LEACHING LINE Ll No. &TLength of tines Properly Line <br /> FILTER SED -1 Distance to nearest: Walt Foundation--- J <br /> t 1 Depth I Size Number d <br /> SEEPAGE PITS Property Line <br /> SUMPS LI Distance to nearest: Well Foundation �� <br /> DISPOSAL PONDS 0 1.1 <br /> i 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 1 <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, l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: "I certify thatsi 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 applicant must call for all required inspections. Complete drawin reverse i e. 8-24-92 <br /> Signed ?( <br /> FI2t'1ningS Bros. <br /> r Title. Date: <br /> FOR EP MENT USE ONLY 1 (� <br /> Data <br /> Application Accepted by ' <br /> Pit or Grout Inspection by Data, — <br /> Final Inspection by Dat <br /> Additional Comments: <br /> Applicant - Return 031 Copies to: San 1oa9, EnvironmentaliHeal htPermit/Services <br /> P 1ery601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> 4 EEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ATE PERM17'NO. <br /> INFO <br /> r <br /> . EH 13-24(REV.}IN W W r 0 <br /> EH 14.26 <br />