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APPLICATION'FOR PEMIT <br /> SAN JOAQUIN COUNTY PUBLIC EfEALTH SERVICES <br /> ENVIRONUENTAL, HEALTH DIVISION <br /> 1601 E. HAZELTON AVS. , PHONE (209)46$--5420 <br /> P O BOX 2009, ST0CKTON, CA 95201 <br /> I . ES I YSAR FRQU D.IkT�ISSUM) <br /> (Ccmplet:e in Triplicate) <br /> Applicatloa Is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made it: c-=*Bance v'ith San Joaquin County Ordinance No. 549 and 1952 and the Rules and Resulatioae of San - <br /> Jarrquta Ccunty Public Health Services. <br /> 1 O <br /> ti. Job Address C' "`'nom' �-citr �t Size/Acreage <br /> Ear .] O� L ,,,lddreu 5� t.` rrT7i^''�a..�, UA. Phone C_4 *313–Cz <br /> Owner's Name - <br /> �.a. <br /> Contractor�(�-?TGA,--.Address �`� v to 9s691 License No. S SZ E g Phone 9!L 7 1►L <br /> TYPE OF WELLIPUMP: NEW,*JELL 0( WELL REPLACEMENT ❑ DESTRUCTION ❑Out of Service Heil ❑ <br /> PUMP INSTALLJ.TION 0 SYSTEM REPAIR ❑ O?HER [J 1lonitorirtQ Help �– <br /> DISTANCE TO NEAREST: SEPTIC TANK Z' - SEWE9 LINES ..��� DISPUS IL FLD. _ PROP.LINE _L�t <br /> { <br /> FOUNDATION '7QO AGRICULTURE WELL LS—Sc- ft OTHER'afELt _. PITSJSUMPS " <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiF:CATIONS d <br /> CI industrial 0 Opon Bottom 0 Manteca Dia.of V,•",II Excavation,jP_t Dia.of Wall Casing <br /> { ,t o��....TPYS Soecd:cabona <br /> n DamatticlPrivete �Gr.+ml Pack L7 Tracy Typo of Casing." r T <br /> r'1 Public CI Diner n Delta Depth ai Grout T"I ltfit>= Type of Grail, <br /> t I Irrigation .,_Apprott.Depth I I Eastern Surface Seal IhstGllsd by��,' �^�^ �= UL <br /> ✓r. _ <br /> Raoair Work Done L] Type of Pump H.P. L11A Slate Work Done <br /> Wall OesiruetMil O Well Diameter M 9csL' rinl k Depth <br /> Depth ^ O Tiller Naterinl & Depth 6-2 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAOOITION t I DESTRUCTION I I IHo lopin system POMAIiid H oubfie sewer er ' <br /> awadzble°within 200 feet.) <br /> Ins serve: Residence-- Commercia.— Other <br /> Number of living units._ Nun,oet of bedrooms r w <br /> Character of Wil to a depth of 3 fest: 111,p to dePl I t <br /> SEPTIC TANK 0 TywmfgCawcity No.Compartments <br /> PKG.TREATMENT PLT.C1 Method at Disposal <br /> Distance to nearest: Well _ F on Property Lina <br /> LEACHING LINE Cl Na.J4 Length of lineso rrgth/size_ <br /> FILTER BED C Distance t est: Well Foundation Pre i,irse <br /> ik - - <br /> j SEEPAGE PITS Depth Sire Number <br /> 1 SUMPS Li Distance to nearest: Well .Foundauon Property Line <br />+ SAL PONDS f] <br /> -2 I hereby Certify that I have prepared IR:a application and that the work will be done in accaidarce wird San Joaquin county ordinances.state lam' td <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the follow.g;"I caraty that in Ina performance of the walk lot which this permit is issued,I shell not <br /> l r amcloy any person in such manner as to become subject 11 workman's compansation laws of California."Contractor's hiring or sub-contracting sigraaure <br /> cerifi+rs the following:-I certify that in thePe ormancs of the work for which this pannit is iuued,I snall employ persons subtest to workmen's compensa- <br /> k ' tion lays offi alif9mis.". <br /> The applica,(t #7 allrIt futrad ifsC pie o drawin on reverse side. <br /> r r <br /> signed%„�---nC r-!1�Y�r1�7�*�l ..a(. Ia'- Titre: Date: -/ f <br /> G+< <br /> FOR DEPARTMENT USE ONLY _ <br /> h ' <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br />—�—a - Additional — <br /> Sj Apy)lcaut - Re%=:all copies to: San Joaquin County Public Health <br /> Services,.Environmental Realth Pervit/Service■ <br /> c { 1501 E. Haselton Ave.. P 0 Haw 2009, Stockton, CA 95201 <br /> INRG AMOUNT drib AMOUNT REMITT'cD- CASH RECEIVED aY DATE. PERMIT NO. „ <br /> yk � I � <br /> xt . Fit 13.34[REY.i r 471 1 <br /> it <br />