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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p O BO%LTON2 09A,VSTOCKTON, CAE. , PHONE 0 —3420 <br /> 95201 <br /> 0vrsxeTm TsgpIRES 1 YEAR FROM DATE ISSUELiZ <br /> CA- (Complete is Triplicate) <br /> to work <br /> in <br /> Application Se hereby �e.to Ban Joaquin <br /> oth innCounty <br /> tule Counr a ty OrdimncermitnHoru5a9ct �and 1662 and ther install eRulea hand aRegulationsof Sana <br /> application is aside in cotes ^ <br /> 7oequin County Public Health Services. �f J- 14 0?6' <br /> Koh Address _'�-U4. n� DL/1 'N f/Y _e _ City S�C!{fOM Lot Size/Acreage !� <br /> {/ R'064 b* �/� Address J�O¢� ��COF_/Y ,/d.TE Phone <br /> I <br /> Kw <br /> Names , <br /> . \ License No. Phone <br /> ontractor y rr'L F - _Address <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ <br /> YPE OF WELT L/PUMP'. OTHER ❑ Monitoring Well [IPUMP INSTALLATION CI ?W pSYSTEM REPAIR <br /> SEWER LINES -.DISPOSAL fLD. PROP. LINE <br /> DISTANCE TO NEAREST:'SEPTIC TANK PITS/SUMPS <br /> `~— FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Die. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> E-1Industrial7 of CasingSpecifications <br /> [a Domestic/Private. ❑ Gravel Pack ❑ Tracy Depth of Grout Soot Type of Groin - 6 <br /> Cl Public ❑ Other fl Delta <br /> Approz. Depth I I Eastern --Surface Soul Installed by <br /> I I Irrigation State Work Done- <br /> Repair Work Done LJ Type of PUMP H.Pr.t , t <br /> i Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth <br /> 1, TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION I I DESTRUCTION I 1 avaitable within o aspic a200 feet.) if public sower Is <br /> I Installation will serve: Residence_ Commercial;-Other - Z <br /> Number of living units: _ Number of bedrooms <br /> Water tabledepth <br /> r Character of coif to a depth of 3 feet: No. Compartments <br /> I` SEPTIC TANK. ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ Property Line <br /> Distance to merest: Well Foundation tx y <br /> Total length/size _ <br /> b LEACHING LINE L1No-8 Length of lines Property Lim <br /> FILTER BED CI Distance to nearest: Well Foundation <br /> tSi:e Number <br /> j -SEEPAGE PITS 1 Depth Property Line <br /> SUMPS LI Distance to nearest: Well foundation <br /> ` DISPOSAL PONDS ❑ state lews, and <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> r Homey any Parson in such manner as to become subject to woNmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that in the performanca of the work for which this permit is issued, 1 shell employ parsons subject to workman's compensa- <br /> tion laws of California" _ <br /> The applicant must call for all <br /> required impactions. Complete drawing on reverse side. <br /> Signed K r AA�1 -L= -�'� Title: <2 A Date: l� <br /> I FR\R\DEPARTMENT USE ONLY <br /> I /n <br /> Appliutbn Accepted by -� Data res Dmer,�[�z- <br /> ' Pn or,Grout inspection by <br /> Data Final Inspection D <br /> t <br /> f Additional Comments:_ _ ._ - .. <br /> j Applicant - Return all copies to: San Joaquin county Public Health <br /> Services, 17rvSroamentel Health Permit/Services <br /> i 2ft.1!,192-Le -bl.z LD IF Ai* 1601 E. Hazelton Ave„ P 0 Boz 2009, Stockton, CA 95201 <br /> 1, FEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> `r INFO q� <br /> F fit 1a24IRfV.Ir+e1 �,� ro�T 2!. )- -�.3'�I <br /> fes to ze <br />