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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O HOF► 2008, STOCSTON9 CA 88201 <br /> (209) 488-3447 <br /> EMIT MIR= I YEAR EM DA IS&= <br /> (Complete is Triplicate) <br /> Application is hereby mada•ta Sea Joaquin County for a permit to coaetruat ead/or install tate vork hetreir, described. This <br /> application is made in cawUeace vith San Joaquin County Ordinanoe No. 549 and Uft cad the Rules and %gW&Uow of Sart <br /> Joaquin County Pablia Heaa1thh Services. <br /> .lob Address; �..�� (��-� .ffi QTY City5;1Lot Sim/Aar-~ ~S C - <br /> Owner's Name r Address �T d <br /> J <br /> 1 Callao <br /> Contractor a V f �r Addresszy �Q/Ir' G �f / Licanae No. <br /> C5� hyo Phone 310•Lill-6 <br /> PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or Serlrlds WeU <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1+1 N it:oring Hsu ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK VL-' SEWER LINES -%- Sri DISPOSAL FLD. FROP. UNE <br /> FOUNDATION = lO or AGRICULTURE WELL : ' OTHER WELL ti P"/SUMPS <br /> NTE ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> s ❑ Open Sonora 7 Manteca 01a. of Well Excavation� 2 OIs. of Weil CNINNI <br /> it/ ate ❑ Gf" Pack ❑ Tracy Type of Casim. .� Speplkaf ons <br /> tPWork <br /> I'1Other 13Delta Depth of Grout Sraip Type of Grou at Aomoa. Depth Esstam Surface Seal brstagad by Dona U Typo of Pump H.P. Stan Work Dorn <br /> Well Daatnwtkm ❑ Well Diameter BaLLing Material 4 Depth <br /> Depth M-fel bAl,0 -1-t6 Fil;ier Ifatsrlal A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIAOUNTION cO DESTRUCTION 0 (No seput;system pwffd ted if pub5c sewer is <br /> available within 2W feet.) <br /> Instafletfon wiI1 saws: Residence^ CommercW— Other-- <br /> Number of livhtg unties: Number of badroa ns <br /> Character of coif to a depth of 3 feat: Wats table depth <br /> SEPTIC TANK O Type/Mfg Cs►'tacttY No. Compartm nia <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Durance to nearest: Wed Fowvlation, Proped Lina <br /> LEACHING LINE ❑ No. 6 Length of tines . Total tenth/size <br /> FILTER BED ❑ Distance to numst: WeU Foundation _ Property Line <br /> SEEPAGE PITS I I Depth Sim Number <br /> SUMPS Ll OisuwA to r4arest: Wag Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 hereby Cenify that I he" prepared 0'al application and that the work will be dans in accordance with San Joaquin county onihniees,state laws, and <br /> rule and regulations of the San Joaouin County <br /> Moms owner or Econsod agent's signature taridurs the following: "I Certify that in the pertermance of the work far which this perrttii Is issued, f shag not <br /> amPloy any Person In sorb nowAr as to became subject to workman'a compensation laws of Caiiforrda."ComrectoYs hutrtg or sub-contras tp sgnature <br /> certifies the following: "I cartW that in the performance of the work for which this permit Is issued, I Shah ampby psmans sublact to workman's eanpsraa• <br /> tion lays of Wamfa.•• <br /> The applicant U <br /> far all required inspscOons. Complete drawing on rwsras stria. <br /> SIQ,od r` Ap n a Title: di p d l 5t '05f Date; Lf -dMi <br /> FOR DEPARTMENT 118E ONLYt,�I <br /> Appgestiort Aw;epted byyData � [ Arae a <br /> Pit or Grow. Inspection by Dais /Final Inspaatian by Dema f r <br /> Addiftrad Conumnis: l� T ! 4, pa;mt , 0 '�W� <br /> I r <br /> AppLIaaat - Return all copies tot RAN JOAQUIN t30U>T'tTf DBLIC =JTH SERVICES dt5i <br /> ENVIRONMENTAL HEALTH DIVI8ION PERMIT/BBRVICES4413 N SAAB JOAQUIN, P 0 SOX 2W9r STOC$TON, CAIN0 FEE AMOUNT DUE AMOUNT REMITTED CK 0 ASH RBCEIYfD 9YENI3-:�INEV °D db� rr1Gt <br /> �N:aje <br />