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L APPLICATION FOR PERJUT A <br /> SAW-'JOAQUIN COUZM PUBLIC HRAT-TYSERVICES <br /> VI TAL HRAT TH DIVISION <br /> 445 X SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKMN, CA 95201 <br /> IBES 1 YEAR FROM DA PF T cerTlan <br /> (Complete in Triplicate) <br /> Application is byto Sae J� <br /> applleation is made in OC usz County for a Permit to construct and/or install the York herein described. This <br /> oaquln County Public Health <br /> J alere ices.with Sam Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Health Services. <br /> Job Address 840 S . Cherokee Lane <br /> City Lod; Lot Size/Acreage <br /> Owner's Name --Cato Pools <br /> Address 840 S rharokpp f a n o <br /> Phone - <br /> Service PO Box 950 209- <br /> TYPE <br /> Oil Eauioment/ 1+oaress San Anriraac ('AojOn�o <br /> TYPE OF WELL/PUMP: License No. '�41 7 phone _ <br /> NEW WELL O WELL REPLACEMENT L7 DESTRUCTION O Out of Service well O <br /> PUMP INSTALLATION ,� SYSTEM REPAIR ❑ OTHER O Monitoring Yell <br /> DISTANCE TO NEAREST: SEPTIC TANK —N n n o SEWER LINES C 1 n <br /> S aDISPOSAL FLD. PROP. LINE <br /> FOUNDATION — 1 CZ r AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS _ <br /> O Industrial O Open Bottom G Manteca Oia. of Well Excavation <br /> n Domestic/Private ❑ Gravel Pack* rrTAY Type of Casing Dia. of Wen Casing <br /> Il Public )(Ott Specifications <br /> 177 Delta Depth of Grout Seal <br /> I I Irrigation Type of Grout <br /> _Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. <br /> Wall DlsttuctionState Work Done <br /> O - WeN Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 1 ) (No septic system permitted it public sewer is <br /> Installation w81 serve R available within 200 feet.) <br /> esidenst_ Corrlr^srt i l_ Other <br /> Number of living units Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. O Type/Mfg CapacWater table depth <br /> ' <br /> PKG. TREATMENT PLT.O m' No. Compartments <br /> Distance to nearest WeNFoundation ptMethod of Disposal <br /> �y �NT <br /> LEACHING UNE O No. i Length of lines <br /> a .FILTER SED Total leve <br /> (� ❑ Distance to news= Wall Foundation 1�RY <br /> SEEPAGE PITS k 1 opd► S;j, FeR�fC HEALTH SERVICES _ <br /> SUMPS LI c 0istancst to+wrest We11 <br /> DISPOSAL PONDS ❑ Foundation <br /> t hereby Certify that I have prepared tflis <br /> application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San Joaquin County <br /> Hone owner or licerw d agent's signattre oartifiee the following: "t <br /> Y any pts such tt�ariner as g: certify that in the performance of the work for which this permit is issued. I shall not <br /> certiliM sut>lect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> Son of '1 eertily that kn tffe part nen of the work for which this <br /> Permit is lensed,t shall employ persons subject to workman's comPensa <br /> t Complete drawing an reverse side. <br /> "Pkm <br /> s*gf1ed r- President <br /> ei.t a is Date: 1/11/93 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date SAt�3 •ars <br /> Area <br /> Ph Or Grout Inspection by Date <br /> _ { ` Final Inspection by Date <br /> Addhlonal Comments: �/� , (��` /1n_C,061-t✓ Anz <br /> Applicant - Return all copies to: San Joaquin County Pub c Health Services <br /> Savironmeutal Health Permit/Services <br /> 445 d San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DtJE AMOUNT REMITTED YKINFO CjR11C1j1V73E,,y DATE PERM17'NO.EM 1}24 laty.iwEN14y $89 . 00 9 ' 1y7 <br />