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} <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY -PUBLIC B,EALTH SERVICES. <br /> BNVIRONfdENTAL HEALTH DIVISION <br /> P O BOX 2008, STOCKTON, CA 95201 . <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> Aypllcatlon is hereby grade to Ban Joaquitl County for a permit to construct and/or install the work herein deter a <br /> applieatloo to ode in **41ta.nce with "A J"Iloin County Ordinance llo. 549 and 1662 and the Rules and Reaulatio s of San <br /> Joaquin County Publlt Health Servicei. -AV,4J 0q4-OSS Z I <br /> Job Address E�YO F D.ONN City Lot Size/Acreage 164e- <br /> Owner's Name __ Address _LL5;-QAAb4egv&� Phone C19Y-Flo Z- <br /> �sZ 3 ,2i v E.Z s2vdp <br /> COnlriclojrjr€QL� iye,�T _Address___ �F14/�` d License Ho. 470 Phone tw <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out or Service weal p <br /> PUMP INSTALLATION O SYSTEM REPAIR C} OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK ,lYA--_ SEWER LINES Zf�L •,_ DISPOSAL FLDI_Y/A PROP. LINE Vim•.. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL,_ PITS/SUMPS `. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom O Maniacs Dia, of Will excavation Dia. of Well Casing <br /> .200 <br /> (9 Domistie/Private XGravel Pack ❑ Tracy TY66 of Coiin L <br /> tl SpecilicationsS-C",40 <br /> 0 Publie (A Other 17 Delta Depth of Grout Seal St)gr,+ Type of Groul�E r6r(/_ <br /> G lrlivalion 76_Approx. Depth O Esitern $urlaci Soul Installed by o /� <br /> Rapalr Work Done U Type of Pump H.P. Stag Work Dona _ <br /> Well Destruction O Well Diameter Sealing ISaterial A Depth <br /> Depth tiller katerial i Depth <br /> TYRE OF SEPTIC WORK: NEW INSTALLATION D REPAtR/ADQITION Li DESTRUCTION ❑ 040 :split system permilted it ptiblic.sewer is <br /> available within 200 leas.) . <br /> Inlfafle.t1011 will--Wr -: Realdence � _ - <br /> - --Comrniaciil�_`-Olh� — - - <br /> Numbir of living units; Number of badroomi - - <br /> Charscter of /oil to a depth of? fait: <br /> SEPTIC TANK. Water table depth <br /> O Type/Mfg Capacity_____„' No. Compartments <br /> PKG. TREATMENT PLT,0 <br /> Distance to neared: Well Method of Dispoial <br /> �.� Foundation Property Lina <br /> LEACHING LINE Cl No. & Length of lines <br /> FILTER BED n Distance to nearest: Well es Total lengthlsi:e <br /> Foundation � Properly Line <br /> SEEPAGE PITS 11 Depth <br /> � Sirs „ Number <br /> SUMPS <br /> L'I Distance to nearest: W411 ___� Foundation <br /> DISPOSAL PONDS Q _ Property Line <br /> ------------ <br /> f hereby cattily that I have prepared IhN applicalion and that the work wilt be done in accordance with San Joaquin county oidinancei, state laws, and <br /> I' roles and regulations of the San JOsquln County <br /> Home owner or Ilcinsed igenl's eignalure certifies the lollowing; "I C41"IilY-that In the performance of the work for which lhis permit ii issued. I shall not <br /> employ any potion in such manner as to become subject to workmen's compensali0n laws of California." Contractor's hiring or lub•contracting signature <br /> cenifiaa the fallowing:'"I COMily that in the riormanci of the work for which this armil Is iisuid, I shall em to <br /> tlon laws of Cilifornla." p <br /> " p Y Persons Wbject to workman's compensa• � <br /> The 1pp1[eant inu eaI r all req fired i sp+diona. Complete drawing o reverse ilds. <br /> Signed <br /> ' Title: ,Qj - •� ,I <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application A Copied by <br /> Data Area <br /> Pit Or Grout lrspiction by i <br /> t Date Final inspection by <br /> Additional Comment*: Oats <br /> I <br /> Ayplicmt - Return all copies tot CAH JOAgUIH COUNTY PUBLIC HEALTH 88RVICS3 <br /> ENVIRONMENTAL HEALTH DIVISION PZttMIT/S9RVICss <br /> 445 N SAN'JOAQUIN, P o BOX 9009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMitTED RECEIVED BY <br /> CA N DATE PIA 17•NO. <br /> 04 l3•24 t11t:V.rte N ' <br /> IH:r•as _ <br />