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APPLICATION FOR PERMIT / <br /> SAN JOAQUIN COUNTY PUBLIC HEAD T <br /> ENVIRONMENTAL HEALTH D <br /> PAYMENT 445 N SAN JOAQUIN, PHONfi (2X¢�8-3420 <br /> RECEIVED P O BOX 2009, STOC%TON, �n �'f9 <br /> SEP 2 7 1993 PERMIT EXPIRES 1 YEAR FROM S <br /> JOAQUIN ( Omplete in Triplic@)U � <br /> SANJOAQ 5r2323 -i1E--`La✓F_( 4c� l�fJ /Nr V <br /> ��kt1WEA6T3lt �IS" Joaquin County for n permit to construct i work herein scribed. T s <br /> E Ipl x¢*'Xs�k mee with San Joaquin County Ordinance No. 54 an m <br /> 'ib•�Doun y Public Health Bery ea. I ,� <br /> Job Address , City Lot Size/Acreage A , <br /> Owner's Name 'l •Address 1R in F- z� � f Phone <br /> Contracts t� Address Al� License No.1 fllx_ _Phone — 11I v'J <br /> TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT 11 CTION 9ery <br /> DESTRU ❑ Out of Lee Well U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE m <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ I dustrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Wall Casing <br /> orreatic/Priwte ❑ GravelPack C1 Tracy' Type of Casing Specilicatlona <br /> I'I Public fl Other (1 Delta Depth of Grout Seal Type of Grout lam' <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ill("I H.P. State Work Done _ <br /> Well Destruction ❑ Well Diamet'e'rU Q. Sealing Material i Depth <br /> Depth ��^yf y Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sower iinot available within 200 feet.) <br /> Installation will serve Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of toll to a depth of 3 fast: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. d Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to merest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> 1 hereby certify that I haw prepared this application and that the work will be done in accordance with San7oaquin county ordinances, state laws, <br /> rules and regulations of iha Sen Joaquin County <br /> Hone owner or licenied agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shemploy any person in such manner as to became subject to workmen's compensation laws of California." Contractor's hiring or subcontracting sigcertilles tha to wing: "1 cettify that in the performopce of the work for which this permit is issued, I shall employ persons subject to workman's comtion Is <br /> The s m lust cell fora quirad insp , trona Complete drawing o e side. — <br /> Signed Title: Date: <br /> FOR DEPARTME USE ONLY <br /> Application Accepted by Date `q Area aCV <br /> Pit or Grout Inspection by Date Final Inspection by 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 Box 2009, Stkn, CA 95201. <br /> F <br /> EE A UNT DUE AMOUNT REMITTED Ce RECEIVED DY DATE PERMIT'NO. <br /> EH t ala lafV.t,aa. <br /> H Ila 7e 5 � ) D�� <br /> E <br />