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skAPPLICATION FOR PERNI <br /> SAN JOAQUIN COUNTY PUBLIC HEALWES <br /> ENVIRONMENTAL HEALTH DIVI �►i <br /> 445 N SAN JOAQUIN, PHONE (209 �0 <br /> P O BOX 2009, STOCKTON, CA <br /> (Complete in Triplicate) <br /> Application is hereby, made to San Joaquin County for a peralt to conmtruct and/or tnetall the work herein described. This <br /> application is aide in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Re/ulatioon of Baa <br /> Joaquin Counter Public HealthServices. <br /> Job Address- ` / r 7 �• City c Lot Size/Acreage ' <br /> r <br /> Owner's Namem� Address -52 �j r 7 ,' Pfione <br /> Conlrac it Address &, License No.,� Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Ye12 Cl <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER ❑ Monitor" He11 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing <br /> 11 Oornesfic/Private O Grassi Pad* O Tracy Type of Casing Specifications <br /> I'3 Public 1'11 Other (l Dome Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth t 1 Eastern Surface Seal Installed by <br /> Repair Work Done U Typo of Pump M.P. State Work Done, U <br /> WWI Destruction D Wolf Owristor Sealtnig Material i Depth 09 <br /> Depth tiller Material A Depth ^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLA ION I� PAIR! DDITION DESTRUCTION INo septic system permitted If public sewer is <br /> S�2 rC c�ra�r or G ,� available within 200 set.) <br /> Installation will serve: Reaidertce Few� Other P1.4r►-e oI�' ..1= *.�a5/ 7� <br /> Number of living units:�— Number of <br /> Character of sol to a depth of 3 hat: > Warr table depth �- <br /> SEPTIC TANK {a Type/Mfg ,ity No.Canpartrnants 2--- <br /> PKG. TREATMENT PLT.O `�.J r Method of Disposal a <br /> Distanco to nssast: wet--- Fpundolion_ Property Line r <br /> D <br /> LEACHING UNE No.A Length of lines 1 Tr�taf krtgth/size <br /> FILTER BEO 1:1 Distance to neareat: Welt Foundation 1�. Property Una s <br /> SEEPAGE PITS I I Depth Sir Number. <br /> SUMPS Ll Distance to nesraR: Wear Foundation Property Lina <br /> DISPOSAL PONDS U <br /> hersby comity 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 ban Joaq*rlst County <br /> Houma owner or ficensed agent's signature certifies the following: "I comity that in the performance of the work for which this permit is issued,I shall not <br /> employ any person in such manner ae to become subject to workman's compensation Wars of California."Contractors hiring or sub-contracting signature <br /> Certifies the following:"I unify that in the performance of the work lot which this permit is issued,I shall emptey peraono subject to workman's compenss- <br /> bon bawe of Califon .- <br /> The a toe IN r t etions. Complete drawing on reverse si <br /> Signed Title: <br /> ~ FOR DEPARTMENT USE ONLY S/1%Cyf�D� r <br /> Appiieatlon Accepted by Oslo Aha , <br /> Pit or GrouAddlilomw t I ion by Date-t----�— Final Inspection by Data <br /> -9 G3 <br /> Applicant - Return all copies to: 8anJJoaquin County public Health 8ervicea �.�r3� lt� ��/a✓�+7z4� J <br /> tinvironmental Health Permit/Services xc�ry�rr,ti .Tj� L.,Aff��la"w <br /> 443 H Baa Joaquin, P O Box 9008, etkn, t]A 95201 Fj a_ /tu0't1 l�al.�7„rt/s <br /> S� <br /> I�atl / 1 CK <br /> LnnF� AMOUNT DUE AMOUNTRE/MIITTED CASH RECEIVED By DATE PERMtT'NO. <br /> . F.:1 tYsr IIUV-tier 5.�'t 1 <br /> v� u..�5•�+�..s <br />