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" � • APPLICATION FOR PERMIT• <br /> U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES''r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin Ccurl for a permit to construct and/or Install the work herein described. This <br /> application is aside in cotlisul vith San Joaquin County Ordinance No. 519 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County biblic Hui Services. <br /> Will -1 ipo may- _ A��y I1�AI <br /> Address ZQµ r.Q� .�' I�'.ArAMa✓ AOa( Cry Lot Size/Acreage# :10 <br /> S <br /> 49-71 CLCAt's <br /> Owner's Name w Pally�Li Address 93 K �' f f Do1.t.L�o �� ST�� Phone <br /> ConbactoA, eA Addre55Z= �^^"- 4?%J@aicense No. V1CSnTNr Ph.. <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well �x <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS. <br /> `r1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS e� <br /> CI Industrial ❑ Olsen Bottom ❑ Manteca Oia. 01 Well Excavation�_' Dia. of Well Casing <br /> CI Domestic/Private Gravel Pack lf(Tracy Type of Casing- 41 4 Specifications <br /> I'1 Public 1­1 Other n Delta Depth of Grout Seal '2-S Type of GropAdw—sr"Of <br /> Inigation _.Approx. Depth I I Eastern Surface Seal Installed by L sVld'tl M-W ,r <br /> Repair Work Done 0 Type of Pump H.P. State Tork Gong <br /> Well Destruction ❑ ell Diameter Sealing Material k Depth t <br /> X wiwvitrnj HW 0th !.[e r Piller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units:_ Number of bedrooms <br /> Character of wit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to neareaa Wan Foundation Properly Line <br /> SEEPAGE PITS ; I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 hereby canify 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 regulaliorts of the San Joaquin County <br /> Home owner a licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I"If not <br /> employ any person in such manner as to become subject to workman's compensation lava of California." Contractor's hiring or sub-contacting signature <br /> certifies the following: "f 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 California.' <br /> The applicant must call r ired-ic tions. Complete drawing on reverse side. I <br /> Signed K_ `Z•""` _ Title:+M!W] e,Okl xfW4rAA9ra Date:'t 7J&T <br /> FOR DEPARTMENT USE ONLY �/!yam ^� <br /> Application Accepted 6y _J� Data tt-" ��Q� Aroa (G�� 1 <br /> Pit or Grout Inspection byzl Date Final Inspection by Q Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public elth <br /> Services, Erivironnental Health Pewit/Bervices <br /> 1601 E. Ranelton Ave., P 0 Boa 2009, Stockton, CA 95201 <br /> INfO A�MjOUNT DUE <br /> AMOUNT REMITTED CAA SHR RECEIVED BY DAC.TTEn PERMITNO. <br /> ' EEH 3_24 M tats REV.1/.51 7�/i1 �7 IVO` ��� �IZJ V7 Iq <br /> Z •d LJ (.J L OOZE 13Cb3SH-1 d WdbT :b 6002 LT dUW <br />