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wet <br /> � APPLICATION FOR PgR1dIT <br /> SAN JOAQUIN COUNTY PUBLIC 'HMTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 'PZ ,TD� <br /> 1� iLsS g 445 N SAN JOAQUIN, PHONE (209)468-3420 Z� 367q--Q j <br /> 2009, STOCKTON, CA•95201. <br /> BOX P O <br /> OCT 0 9 1992 p T EXPIRE YE FR M D T it-17y <br /> (Complete in Triplicate) <br /> ENVIRONMENMHEaTH permit to construct and install the work herein described. This <br /> Applica �1�e-to $e'a Joaquin County for s ty <br /> liance with San Joaquin Co ty Ordipp�ce No. 5�9 and iB62 and the Rules and Regulations of a <br /> application is Made in Comp �J _ I <br /> Joaquin County Public Health ServeA• `! (�'L a 5 ,�T1 Lot Size/Acreage <br /> fF,P/v city �xf <br /> Job Address S'S 'A Phone <br /> Address <br /> Owner's NameS1ZZ6� Phone <br /> mY t Zb IF. m (;!2T S1+ License No. <br /> ddress DESTRUCTION <br /> Contract WELt REPLACEMENT ❑ <br /> NEW WELL ❑ OTHER ,A' <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ / � 5 <br /> PUMP INSTALLATION ❑ DISPOSAL FLO, 6 <br /> SEWER LINES --- /ID11 � <br /> DISTANCE 70 NEAREST: SEPTIC TAN1.K —� AGRICULTURE WELL OTHER WELL <br /> FOUNDATION r� f j„0 t{pl <br /> l INTENDED USE TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS �T <br /> 1 pis. of Well Excavation <br /> C1 industrial ❑ Open Bottom ❑ Manteca <br /> 0 Tracy Type of Casing_ 1(ij <br /> Cl Domestic/Private ❑ Gravel Pack Other n Delta �Z� u" <br /> I"1 ;'I- �� Depth of Grout Seal •�t <br /> i'1 Public Surface Seal Installed by W l f'HD <br /> 1 1 Inigatian Approx.;Depth I 1 Eastern State Work Done LI <br /> ' H.P. <br /> Repair Work Done L] Type of Pump -- Sealing material A Depth <br /> Well Destruction ❑ Well Diametsi �-- Filler material i Depth <br /> Depth ; <br /> available within 200 feet) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRlADDITION l I DESTRUCTION I 1 (No septic tted system permiit public sewer is <br /> 1 Installation will serve: Residence Commercial Other---�— �y <br /> 4 Number of living units: Number of bedrooms Water table depth <br /> r <br /> Character of soli to a depth of 3 feat a Capacity.� No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> I PKG. TREATMENT PLT.❑ IProperty Line _ <br /> D'istance,to nearest. Well Foundation -- <br /> Total length/size <br /> 1 LEACHING LINE C1 No. b Length of linea Property Line — <br /> ; �-- <br /> l FILTER BED 0 Distance.to newest: Well <br /> I Number <br /> SEEPAGE PITS i I Depth Size property Line <br /> k SUMPS LI Distance to nearest Well <br /> Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared ihislapp�ti ion and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaqu County following: , nature <br /> Home owner or licensed agent's�as t r comma subject workman'srtcompensatFon lawsofCaiilopniah�Contractor's which <br /> osub-contracting rmit is }sign ll not <br /> employ any person in such manna . <br /> ceRifies the fallowing: "l wrtify that in the performance of the work for which this permit is issued,1 shall employ persona subject to workman's compsnsa- <br /> ! tion laws of California.•• <br /> The applicant it call for all r u ed lnspgctions. Complete drawing on reverse side• LS'� Date. d <br /> Title: =EF r(a r �•5 <br /> I Signed <br /> F R PARTMENT USE ONLY <br /> Date G Z Area J <br /> Application Accepted by _ V Date�� <br /> Date Finsi Ina tion by <br /> kPit or Grout Inspection by I N , <br /> Additional Comments: Q y <br /> Applicant - Retur all copies tat EnvironmentaloHealth Permit/Servicespublic Healtb vices <br /> ! 445' N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> e p K RECEIVED BY DATE AERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO V(/� Q <br /> r EN 13-24 tREV.I/it d, <br /> EX 1426 <br />