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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES�a,N `710 a J��7EM ri'''p, <br /> �f <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Kim, 15 J <br /> iR 0 BOX 2009, STIOICKTON, CA 9.5201 <br /> (209) 468-3447 NOV 1 6 1990 <br /> PERMIT XMIRAS I YEAR OROM DATE ISSUMVI RON`AENTAL HEALTH <br /> (Complete in Triplicate) <br /> PEERMIT/SERVICES <br /> Application Is hereby made.to San Vosquin County for a permit to construct and/or install the work herein described, This <br /> application In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address cAtsilza City Lot Size/Acreage <br /> jtr <br /> Owner's Name Address Phone <br /> _: <br /> x,a3�_3_�L,:ense No.4_/1C3?62_ Phan <br /> Conitacto4u4l� A:&�ddress &.. <br /> TYPE OF WELL/PUMP: NEW WELL 7-1 WELL'REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (I Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> *Domestic/Private 0 Gravel Pack, 0 Tracy Type of Casing Specifications <br /> ZI Public ('I Other El Delta Depth of Grout Seal Typo of Grout <br /> a Irrigation —Approx. lbept4 0 Eastern Surface Soul Installed by <br /> Repair Work Done Type of Pump: H.P. State Work Done <br /> Well Destruction � E) Well Diameter Sealing Material &.Depth <br /> i Depth Filler Material k Depth; <br /> F <br /> TYPE OF SEPTIC WORK; NEW INSTALLATfON-0—REPAIR,IA06tTION1.I DESTRUCTION 1=1 IN o septic system permitted if pubtic sewer is <br /> will serve— .----avai-labie within-200 lost.)- <br /> Installation.w -Residence— Commercial— Other <br /> Number of living units: — Number of bedrooms i <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC'TANK 0- Type/Mfg --Capacity No. Compartments <br /> XG:7UEATMENT PLT.0 t. Method of Disposal <br /> Distance to.neerest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Lengih of lines Total length/siz <br /> FILTER BED n Distance to nearest. Wolf Foundation Property Line <br /> SEEPAGE PITS If Depth Silo 7 Number <br /> SUMPS LI Distance to nearest: �Woll_l Foundation— Property Line <br /> DISPOSAL PONDS 0 J� It I <br /> I hereby certify that i have prepared INS apphaflon-and_th;l ihe-wwk will'be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Son Joaquin County </ I <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 sub-contracting 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." i <br /> The applicant mut all for all squired inspections. Complete drawing on reverse side. <br /> Signed X_(: � Titl®: Data: TO <br /> Fog DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 0 <br /> Additional Comments: <br /> Applicant - Return all copies to. 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> •ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> '445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT FtEmi7ED - CK RECEIVED BY DATE- ioEwM1_1_-w_71 <br /> INFO CASH <br /> CH 13 24 IA /asp EV�I <br /> Em 114-.28 <br />