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APPLICATION FOR PERMIT <br /> n- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCSTONO CA 95201 <br /> (209) 465-3447 <br /> PERMIT ARIBBS 1 Y M PROM DATE ISSUE <br /> (Complete in Triplicate) <br /> Application is hereby Sade to San Joaquin County for a permit to construct and/or Lasts)) the Mork herein described. This <br /> application to Made in emiliance with San Joaquin County Ordinance No. 549 ind 1862 and the Rules and ResulAtions of San <br /> Joaquin County Public Health Services. <br /> Job Address ...� � t1 [�. IV oWg -l" City 57OCkTnry Lot Size/Acreage <br /> -2ck <br /> Owner's Name U4kiky, 2CQ Q Address /32 0 Ly Phone y 3 <br /> /1�0AErl6 d °l <br /> Conlractor(iS?Lc►rdSA f f1,rwf!!1 Address 2-'3 ,ZrdfIf &Q, License No.Yt/ 6 l7o Phone "3 -�? <br /> TYPE OF WELL/PUMP:UMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION Cl Out of service well <br /> PUMP INSTALLATION © SYSTEM REPAIR Cl OTHER U Noaitorie� WellJhr <br /> DISTANCE TO NEAREST: SEPTIC TANK 4AEF SEWER LINES /D b DISPOSAL FLD. PROP. LINE 4� <br /> FOUNDATION —ZI-L— AGRICULTURE WELL OTHER WELL PITS/SUMPS ...,r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> )K Industrial ❑ <br /> Open Bottom 0 Manteca Dia. of Wall Excavation Y Dis. of Well Casing <br /> U Domitmic/Private ❑ Gravel Pack ❑ Tracy Type of Casing, e pe Specifications <br /> M PubNc lit Other IP Delta Depth bf Grout Seal AV X4'It a WAC-0 Type of Grout 6'vr <br /> rJ Iain■tion 3SApprox. Depth C Eastern Surfied Sial Installed by e-77of 0 r S-;,Ci AA--P <br /> Repalr Work Done U Type of Pump 9 4 9 H.P. State Work Done_ <br /> Weil Deatnrcti n O Woo Diameter 01` ! r, Sealing Itaterial & Depth --- <br /> Depth 3S,- Piller Material 8 Depth <br /> TYPE OF SEPTIC; WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION G INo septic system permitted N public sower is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— other <br /> Number of Rvk+q units: Number of bedrooms <br /> Charsew of self to a depth of S feet: Water table depth <br /> SEPTIC TANK 0 type/Mfg Capacity-- No. Compartments <br /> PK0. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Wei Foundation Property Line <br /> LEACHING LINE 0 No. A Length of tines I Total length/sirs <br /> FILTER BED n Distance to nearest: Wen Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be dons In accordance with San Joaquin county ordinances, state Jews, and <br /> rules and regulstions of the San Joaquin County <br /> Nome owner or licensed agent's signature certifies the following: "I certify that In the performance of the work for which this permit Is issued, I shall not <br /> employ env person in such manner as to become subject to workmen's compensation laws of California,"Contractor's hiring or sub-contracting signature <br /> c9niflse the following:"I Certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion laws of Camornw." <br /> The spppcent AINcall for sN required inspections. Complete drawing oft ►N lid S T <br /> Signed - kGt- T1tN 1161" ' <br /> u" Date: 041,4r/ 67 <br /> •�S <br /> "�.�FQR�jEPARTMENT USE ONLY <br /> Application Accepted by Data P' / 3r Area <br /> 2-43 <br /> Pit Of Brent frlspaCOM by Data Final Inspection by Dns <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY pUBLIC HIALTH SNUVICSS <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/BIRVICIS <br /> 445 N SAN JOAQuim, P O gW[ 2000, STOCI(TON, CA 88201 <br /> FEE AMOUNT DUE AMOUNT REMITTFD RECfIVEo BY <br /> INFO CASH DATE PEAMIT'NO. <br /> . t%13-24 rsev.��w�r �, 00 23222 <br />