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APPLICATION FOU PERMIT
<br /> Or C�t-,
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> 1601 F. RAZELTON AVE. , PHONE (209)468-3420
<br /> P 0 BOX 2009, STOCKTON, CA 95201
<br /> 'E I:1 EXPIRES I YEAR FROM DATEISSUED
<br /> (Complete in Triplicate)
<br /> Application is hereby made to San Joaquin C::jurity ror a. perm!" to ccmstruct and/or instail the work herein described. This
<br /> application is made in compliance with San Joaquin County Cr(3inance No. 548 and 1862 and the Rules and Regulations of San
<br /> Joaquin County Public Health Services.
<br /> --fit
<br /> ize/Acrene
<br /> Job Address ....... ------
<br /> g
<br /> Owner's Name .............—.__..._..T._......._...._....._........__....__ Address ........................... Phone
<br /> C L-�I'e,,�e IND,
<br /> Contractor Acire-- ......... Phone
<br /> ......................................
<br /> TYPE OF WELL/PUMP NEW WELL C." VvELIL.. AEPi-ACErOENT DESTRUCTION C1 out of Service Well D
<br /> Monitoring Well
<br /> PUMP INSTALLAI iON I.. ' YSTENI REFAiR F-' OTHER
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ........................... DISPI')SAL FI-D.---.- PROP. LINE
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL-- PITS/SUMPS
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSZTRUCTION SPFCIFICAT}ONS
<br /> ................ .................................. ..........................
<br /> Industrial E-1 Open Bottom i Manteca Dia of Well Excavauon -1............................................. Dia. of Well Casing
<br /> Dornesrici Private I Gravel Pack Trac:, Type of cjs:nq- Specifications
<br /> Public ' Other Depth of Grout Sea! Type of Grout
<br /> Irrikjollor, — Approx, [,,,opch Suffa.0 Suit Installed 1�y
<br /> Repair Work Done Type of Pump H P 8,ate Work Done
<br /> Well Destruction F-1 Welt D,ameter St-,r,1�1'18 L , aft h
<br /> Depth R'.1 yr Matertal & Dkqpth
<br /> TYPE OF SEPTIC WORK NEW INSTALLATION HEPA;R,,aJ1DITI0N GE STR(JCTION info sopoc systern permitted if public sewer is
<br /> ,ii.,jilzible within 200 feet-j
<br /> Installation will serv;.i: Residence--- Commen-,at OTI--c-I
<br /> Number of living units: Mimt- c1f be�J�ooms-
<br /> Character of soil to a depth of 2 feet: Water table depth
<br /> SEPTIC TANK L) Type/Mfg Capacity---- No, Compartments
<br /> PKG. TREATMENT PLT D Method of Disposal
<br /> Distance tr; oearest: Line
<br /> LEACHING LINE LI No. & Length of lines Total kingth./size
<br /> FILTER BED I.) Distance to nearest: VYeil Poondation P(Qpiarly Lme
<br /> SEEPAGE PITS 1 1 Depth ...............-.Siza .................... ........... Nurnuar
<br /> SUMPS i I Distanca to nearest: Well Foundation .........................._ Property Line
<br /> DISPOSAL PONDS (.-1
<br /> I hereby cer0y that I have prepa,ed !his appFcalior,�d lr:,3" tl)() Wv0,k vjl! [)O in vJ9i San Joaquin county ordinances, stale laws, and
<br /> rures and regulations of the San Joaquin Counc,t
<br /> Home owner or licensed agent's signature csr-Dias the following: I i,uvtf;, that In thti of the work for which this permit is issued, I shall not
<br /> employ any person in such manner as to become subject w worlkFnaR's lavis Of Ca0om,a - Contractor's hiring or sub-contracting signature
<br /> certifies the following: -I certify that in the oe-rform8ncai of the v.,,-k for which ffir,permit.is issued, I siiail arripiuy persons subject to workman's comparisa-
<br /> Tion laws of California.`
<br /> The applicant must Cali for all required inspxCFions, con-%plete cir,,,,,;snq or. rsv�nse stdo
<br /> Signed X T=;i& ------— Date:
<br /> FOR DEPARTMENT USE ONLY
<br /> Application Accepted by ................................................ Date Area
<br /> Pit or Grout Inspection by ................................. .............................................--- Final inspe"ion by ................... Date
<br /> Addivonsi Comments:
<br /> Applicant Return all copies to: -'a:c jleaLtr,
<br /> V'C-, F. Ave_ P �) Bcx 200, Otork,�on, CA q5Qi
<br /> FEET --FK——-I- ---- ------- -' ' --I---- ---
<br /> INFO AMOUNT CliijiF ,N40UNT REMiTIED ®r HE"FIVLI) BY DATE PERMIT NO
<br /> 4--
<br /> EH '3,24(REV.
<br /> Ell 4 M
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