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€ APPLICATION FOR' PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE:, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> pSANAvR22 ��� <br /> _ . PERI[IT EXPIRES 1.,,YEAR �a ISS v Vi aNc%H44 ?-, COU91 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein f44;,)jk This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Aegulati �! „Sen <br /> Joaquin County Public Health Services. �'!V <br /> r1 <br /> Joh Address APPxi!I!�'�.Y0 N. 4F fVT 53530/P-1” `� <br /> y �R�TCity 7 {- Lot Size/Acreage X <br /> F <br /> IT¢q,.ls 4!g aM Aril SD,� +�ti-J� <br /> Owner's Name , C.&= _ Address Phone 2-05 826-0643 r <br /> Los efr+aciS,LA 9540 <br /> �I Contractor W-k%r�PS%T . LUN(Ttldress 1 tDIP CAL1"1QrS* e��r4l4cense No. (aO'3(050 Phone ::p 35*"mal <br /> TYPE OF WELL/PUMP: NEW WELL R WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> #s PUMP INSTALLATION 1:1r SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 ,00N3c(c7n4 a,q,y. 32 <br /> Nlr , <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. ofC?¢SWelliCasing 8 <br /> i, fl Domestic/Private IAF Gravel Pack aTracy Type of Casing_M+Lb STALL; Specifications AS3 � 3a1FS 5 <br /> tX Public FI Other s ., t n Delta Depth of Grout Seal 3 112!�_ ITn ce^..•--tType of G out 11400rr MP"�"` ' <br /> i I Irrigation t°�? � Y <br /> g Approx, Depth I. I Eastern Surface Seal Installed by._ 1�1•_ rrti��ld - <br /> Repair Work Done L7 Type of Pump H.P. State Work Done _ <br /> I. Well Destruction ❑ Well Diameter Sealing Material & Depth C) - ' t t;l.rrt5�11T� <br /> ' Depth Filler Materiel & Depth �� ""! 19A 6 G9.#Wdl- PA"_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I AIRIADDITION i 1 DESTRUCTION I l INo septic system permitted if public sewer is S <br /> ,f available within 200 feet.) <br /> installation will serve: Residence_ Comm cial�_ Other <br /> Number of living units: Number of drooms <br /> i <br /> Character of soil to a depth of 3 feet: alar table depth <br /> SEPTIC TANK ❑ Type/Mf Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0 � � Method of Disposal t <br /> Dist nee to t: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines X Total length/size <br /> FILTER BED C� Distance to nearest: Well FoundaY n Property Line' <br /> SEEPAGE PITS 11 Depth Size Numb , <br /> SUMPS LI Distance to nearest: Well IFo0undation Pro r' <br /> party Line _t. <br /> DISPOSAL PONDS ❑ <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 <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, 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 celrtify that in the performance of the work forvGhich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant sst call for'all requiirediiinnsspaecttions. Complete drawing on reverse.side. <br /> Signed X Title: V PAC I'J M_C$e_.S` Date: ¢�l Vi <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by Date , Area r� <br /> Pit or Grout Inspectio b Date Final spection by Date <br /> Additional Comment <br /> Applicant - Return all copies to: San Joaquin County Public Health/ <br /> Services, Environmental Health Permit/Services <br /> p 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> I! FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT'NO. <br /> 26 <br /> • EH 13.24 IREV.i/M 5)1 �Y <br />