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APPLICATION FOR PER13IT <br /> SAN J'OAQUI,N COUNTY PUBLIC REALTH SERVICES <br /> ENVIRONMENTAL 9EALTH DIVISION <br /> 1801 p• HAZELTON AVE. , PHONE 0 BOX 2009, STOCKTON, CA� +3+12Q <br /> 95201 s <br /> r (Complete ip Triplicate <br /> quid County for a permit to construct and/or install the cork herein deecrlbed. This <br /> ApgZicatlon <br /> in hcrelby made,to 86n Joaq <br /> afflication is Grade In compliance With Ban Joaquin County ordin6o Na. 5kg and 1862 and tBe Au1ag sod Regu]8tiorte of an , <br /> Joaquin County Public Reaith Services: <br /> 17750 East Hi hwa 4 <br /> City_U.Q4n � Lot Size/Acreage <br /> .lob Address <br /> Arnold Souza Andress <br /> 17750 East Hi w Phone - <br /> Owner's Name ` <br />` contractorCach� e Creek Drilling_j�j'Address P $ <br /> Of service Well <br /> License No, <br /> WELL REpLACSMENT ['7 bESTRUCTIO but aWell <br /> 0TYPE OF WELL/PUMP: NEW WELL 0 OTHER R bi o ingb <br /> I PUMP INSTALLATION rl SYSTEM REPAIR <br /> _�—. SEWER LINES DISPOSAL FLD,- PROP DISTANCE <br /> - <br /> DISTANCE TO NEAREST: SEPTIC TANK PITWSUMPS ..-- <br /> FOUNDATION Y- AGRICULTURE WliLL _ OTH7 R WELL -- <br /> %r <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Weil Casing f� <br /> C.1 Industrial CJ Open Bottom 0 Manteca Dia. of Well Excavation r�.� Speciflcations.-�---- <br /> t'.3 OomeseiclPrlvate Cl Gravel Pack L-) Tracy Type of Caging__ �-^� <br /> I'l PUbfic 13 Other <br /> f`l pelta Depth of Grout $eal Type of Grant <br /> I i Irrigation __ Appfox, Depth t I Eastern Surface Saul Installed by to yyork pone v <br /> Repair Work Done Ll Type of Pump H.P. J9S�c1C CCm2nt " <br /> t <br /> Well fJeatruction CJ Well Diameter �. -�-- <br /> Sealing Material <br /> tr ne17th <br /> I Filler Notarial 8 Depth <br /> l Depth <br /> TYt OF SEPTIC WORK: NEW tt+!STALLATION t I REPAIR/ADOITION I I oESTRUCTION I I availablelwithin 240 taetl,iad it ptt#ilic t;nwar is <br /> Inslaostion will serve: Residence— Commercial Other --- <br /> Number of living units: �_ <br /> Number of bedroom$ (\ <br /> Water table depth J <br /> Character of soil to a depth of 3 feet; No. Compartments <br /> SE=PTIC TANK a Type/Mfg Capacity <br /> - Method o1 pi$ppsal <br /> f dK TREATMENT PLT. E1 <br /> Olstmnce to nearest: Well _.,., — Foundation— PropartY Line_.�.,..._.-- <br /> Total length/sire <br /> LEACHING LINE L1 No. & Length of lines <br /> E <br /> FILTER BED <br /> Cl Distance to nearest: Well — Foundation Property Line <br /> l Number <br /> SEEPAGE PITS it Depth Sime ���.�.—.. �_ _ <br /> SUMPS �l Distance to nearest:. WON ... Foundation „_ _ Property Line <br /> DISPOSAL PONDS <br /> at the work will be done in accartiance with San Joaquin county ordinances, state saws, and <br /> I hereby certify that I have prepared this application and th <br /> rules and regulations of thq San Joaquln County <br /> "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's Signature Certifies the following: <br /> ecome subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signeture <br /> employ any person in such manner as to b <br /> certifies the following: "I Certify that to the performance of the work for which this permit is issued, t ehaN employ Parsons subject to workman's compensa <br /> tion tswa of California <br /> The applies u I ll for all required inspections. Complete drawing on revers@ side. 4 919 <br /> 0 <br /> Signed X Title: President Data: �---.- <br /> FOR DEPARTMENT USE ONLY .211 <br /> 4� _ Date Area <br /> Application Accepted by -- —-" J <br /> Final tnasteotto y � � ���� ~ Date T �� <br /> Pit or Grout Inspection by Date�..�- — 9 <br /> t3 <br /> $ Additional Commante: �� Ni ' <br /> Applical¢t - Return all cotsies to: Ban Joaquin County Public Health /f� ��� ��Grl��Luc�r <br /> Servlees. Environmental Health permit/Services <br /> 1601 E. Fiatelton Aver F 0 Box 8009, 8tm*tonj CA 95201 <br /> w4A <br /> IN G AMOUNT DUE AMOUNT REMITTEE] CASH Pt CI;IYEO fay DATE PERMIT'NO• <br /> r <br /> IN U-24(Rev,+final <br /> .t41i't42ft >�� <br />