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f <br /> 4 <br /> 4 )APPLICATION FOR PERMIT n <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE {209}468-3420 <br /> P O BOX 20091 STOCBTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE -I-SSUEP <br /> {Complete in Triplicate} <br /> Appllcation is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is madein compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Coun Public Health Service's. <br /> Job Address ' 3 + t 1 ��' City Lot Size/Acreage <br /> Owner's Name lei i� QJJt�CX Address Phone <br /> I6O! fdClOar£ �l I` __ y ---.-LtdMo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENTDESTRUCTION Cl Out or Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIIOTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUM., <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS � ,� <br /> ;Z <br /> C7 Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [l DortrestielPrivate Cl Gravel Pack 0 Tracy Type of Casing_. Specifications <br /> 4 Il Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> - Ovation —.Approx. Depth I I Eastern Surface Said Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Don <br /> Wall Destruction ❑ Well Diameter Sealing Material A Depth , 1 <br /> Depth Filler Material Z Depth <br /> :TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 fee t.I <br /> installation will serve: Residence— Commercial_. Other <br /> Number of living units: Number of bedrooms CAO, <br /> Character of soli to a depth of 3 feet: Water table depth U' <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br />,PKG. TREATMENT PLT. 0 Method of'Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 6 Length of lines Total length/size <br /> FILTER BED Irl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br />,SUMPS LI distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I a that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's mpensa- <br /> tion laws of all ia." <br /> The a u call f all r ins ctiona. Co plate drawing n raver side. <br /> Sig Title. Date: <br /> ep -*OR DEPARTMENT USE ONLY <br /> Application Acct ) <br /> ed bY..... �_.�. . h Date Area <br /> Pit or Grout Inspection by Data Final In by_ZZijr�4 Date !� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O lox 2008, Stka, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'N0. <br /> 1.21 1AEV.r,as) PfL - r o O , p ^5 � <br /> 1.269tv <br />