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r ' <br /> APPLICATION-FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE V9RIt <br /> ENVIRONMENTAL HEALTH DIVISIO — --� <br /> P O BOX 2009, STOCKTON, CA 952 D <br /> (209) 468-3447 <br />! PEUTT FX21=91 I YEAR PROU 17r # <br /> (Complete in Triplicate) , <br /> f <br /> f Application is hereby toada•to San Joaquin County for a permit to construct and/or irt�ta.l], ch <br /> application Is tt+ada In coaPliance with Bars Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Bene <br /> JoaQuln County Public Health Seryiees. <br /> Job Address <br /> l87(, C'ooti-ng L,,L3 D 2 City Lot Size/Acreage f IZ ,QC. <br /> i <br /> Owner's Name uJ E Address LSp33 Lt 1. W A�rJ.�T S I Gtr ?"O k ... Phone 4,64 - IZ2 I <br /> Contraclor7 C,C tori Addre s s2agli r. - a bC_1CT0 License No.SrrJ(.b Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK A"//4 SEWER LINES �`���r -DISPOSAL FLD.�_ PROP. LINE <br /> FOUNDATION -22-L- AGRICULTURE WELL 2ZC 1_ OTHER WELL PITS/SUMPS �A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation ' Dia. O( Well Casing <br /> U Domestic/Private ❑ Gravel Pack O Tracy Type of Casing p G Specifications <br /> Public CI Other ❑ Delta Depth of•Grout Seal "�+GC- <br /> Mp,V/rV4Z A1& �` p Type of Grout CEry�n r <br /> ugaeion --L.I_Approx• Depth ❑ Eastern Surfalee Said Installed by Cos-)r 1a <br /> Repair Work Done U Type of Pump w H.P. Stats Work Dane <br /> Wall Destruction O Well Diameter Sealing Material z Depth <br /> I Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION CJ INo septic system permitted it public sewer is <br /> Installation will serve: Residence Commercial w available within 200 feet.l <br /> Other <br /> Number of living units; Number a! bedrooms <br /> Character of soil to a depth of 3 teat: <br /> SEPTIC.TANK. Water table depth <br /> ❑ TypalMfq Capacity` No. Companmants <br /> PKG. TREATMENT PLT. C) <br /> Method of Disposal <br /> Distance to nearest: WeII Foundation Property Line <br /> LEACHING LINE Ll No. E Length of lines <br />' FILTER HED Total length/size <br /> f7 Distance to nearest: Wail Foundation Property Line <br /> SEEPAGE PITSi I Depth i✓ i.e <br /> Sirs _ Number +' ��4'"' <br /> Cl D <br /> SUMPS � if <br /> Distance to nearest: Well �� Foundation Property Line Ci <br /> DISPOSAL PONDS C3 <br /> ,4 176 r <br /> I zereby canily 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,regulalions of the San Joaquin County <br /> Home ownsr or licensed agent's signature certifies the following: I canily that in theworE•�,`IIN <br /> employ any person in such manner as to become subject to workman's compensation lawsofCalifornia." Contractor•sJh mrsl /g� �o �s �fsshna nae <br /> cartilies the following: "I csnify that In the performance of the work for which this permit is issued• I shall em fo " �su�c p• q signature <br /> tion lawsof California," p Y persons subject to workman s compensa- <br /> The sppatc+n tai all requi ad ins ptions. Complete drawing on tweraa side. <br /> Signed ` <br /> Title: Dale: Q <br /> DEPARTMENT USE ONLY <br /> Applicalion Accepted by r^" <br /> Data tJ Area <br /> Pit or Grout Inspection by Data <br /> --��_ Fins! inspection by Date <br /> Additlonal Comments; <br /> � r• - <br /> ApPlicaat - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENV <br /> 44TH HEALTH <br /> ION <br /> C <br /> SAN JOAQUIN, 0 DOX2009, STO <br /> 5KTON, CA 95201 <br /> PEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> a� <br /> 4/. 14.2r ielV.ii n U �� G V 3 � r�M <br />