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' 1 <br /> APPLICATION FOR PERMIT + j <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV I RONILENTAL HEALTH DIVISION <br /> P O BOX 20091"` STOCBTON, CA 95201 <br /> G249) 468--3447 <br /> PERMIT EXPIR PROM DATE __IRRUM) <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a'-permit:to 'construct and/or install the vork herein described. This. <br /> application is glade is Cotttpliance with Baa Joaquin County Ordinance No. 549 and 1862 said the Rules and Regulations of-ban <br /> Joaquin County Public Health Services. f <br /> Job Ad$rsss 7 —L(�,f f21 U F CitySTOG�TdA1 Lot Site/Acreage t 1Z ACeE <br /> Ownsr'ti Name&M.WL S.4NC c`Z Address 1633 ct) GJAlr-ST_ S7Z C7-0t J Phone 464 -17 <br /> Ccnlratt� ec7 uln , C Address262s,i:F/#l� ,Sr ic�`�S, 9S1oricense No.s1Z -&6 Phone - / <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Sell ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK YVIA SEWER LINES SO" DISPOSAL FLO.6614 PROP, LINE /0' <br /> FOUNDATION AGRICULTURE WELL &24 OTHER WELL PITS/SUMPS -4LI11 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> 0 lndutlrial • ❑ Open Bottom ❑ Mania" Dia. of Well Excavation Dis. of Wall Casing rr <br /> Domestic/Privata .,. _ Gravel Pack ❑ Tracy Type of Casing Specifications t 0 <br /> M Puhlic fa Other 0 Delta Depth of Grout Seal - Type of Grout ENS <br /> rJ 116f; lion 12Appiox:'Depth ❑ Eastern "Surface Seal Installed by i!'0A 7-RA4iOr <br /> Repair Work Done U Type of Pump H.P. Slats Work Done w <br /> Wal Destruction O Wsu Diameter Sealing Material i Depth <br /> - Depth Tiller Material 4 Depth I <br /> TYPE-OF SEPTIC WORK: NEW'INSTALLATION D REPAIR/ADDITION L7 DESTRUCTION C1iNo septic system pe(mitied it public sewer is <br /> available within 200 lest.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT,Q Method of Disposal <br /> Distance to nearest: Wel ; Foundation Property Line <br /> LEACHING LINE Cl No. A Length of lines Total length/size I <br /> FILTER $ED -'- 0 Distance to nearest: Wel) Foundation Property Line <br /> Yt <br /> SEEPAGE PITS i I Depth Sire Number <br /> SUMPS` Cl Distance to nearest: Well -Foundation Property Line <br /> DISPOSAL PONOS ❑ (� <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 `s~ <br /> rules and regulations of the San Joaquin County <br /> Home owner or liesnsed agent's signature Certifies the following: "I certify that In the parlormance of the work for which this permit is issued. I shall not <br /> employ any person In such manner as to become subject to workmen's compensation laws of California." Contactors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the periotmance of the work 10(which We permit Is issued,I shall employ persons subject to workman's compensa-' <br /> tion laws of California:' _ <br /> The applicant anat eah r all r aired sptctions. Complete drawing on reverse side. <br /> ,1 - <br /> Signed Title: UNSu r T Date: 3/-2g/�-5�q 3 <br /> 00, <br /> FOR DEPAR SE ONLY _� <br /> Application ccapted by Data Ares <br /> Pit or Grout Inspection by . Date Final Inspection by Date <br /> Addltlonal Comments; <br /> II <br /> Agplicsat - Return all copies to: SAN JOAQUINCOUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 0 <br /> 445 N SAN JO <br /> A t1I H <br /> Q , P O SOX 2009, 3TOCKTON, CA 95201 ,• ' <br /> FEE ' <br /> INFO AMOUNT DUE AMOUNT REMITTED A H RECEIVED 8Y Ow7E PERMIT'NO. <br /> C 5 <br /> EH 13.24(REV.Il No / �I/ <br />