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7APPLICAT'10N FOR PERMIT <br /> 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZ,ELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 9.5201 <br /> J PERMIT RXPIRES 1 YEAR FROM DATA ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby tie to Sari Joaquin Co'anty for a Permit to construct and/or install the work herein described. This <br /> apPlicatlon is made in c7AP11ance vlth UZ Joaquin County Ordinance No. 549 and 1862�and •the Rules and Regulations or San <br /> Josquin County Public Health Services. <br /> Job Address " Crty4e-Ai! Lot Size/Acreage 09a .91 <br /> V _ <br /> Owner's Name �'Y �t+CxC Address X..(,. \ Poona <br /> Contractor Address icense No.� Q�i/.3rPntane <br /> TYPE OF WELL/PUMP; NEW WELL C WELL REPL EMENT M. DESTRUCTION C Out of Service veil 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER O Monitoring Well L. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT5/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ci Industrial C Open Bottom :✓ Manteca Dia. of Well Excavation Dia. of well Casing <br /> .l Domestic/ptvate 0 Grave! Pack 0 Tracy Type of Casing Specifications <br /> Public Ill Other I n Delta Depth of Grout Seat Tyne of Grout <br /> i lrriflation __ Apprax< jDep:h I t Eastern Surface Seal installed by <br /> t,-D <br /> ':Repair worone• a 7yps.of-Puma_ —. <br /> T State,Work-Done <br /> f Weil Destr}retion 0 Wel! Oiametetr Sealing Material 1 Depth <br /> Depth _ Piller Material i Depth <br /> TYPE Of: SEPTIC WORK: NEW INSTALLATION I I REPAIR fAOOITION'�DESTRUCTION i I Wo se tic system ' <br /> p permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation well sarve: Residence Commercial Other _ <br /> „.•__Nu»ybsr of living units: of bedrooms <br /> Character of sat.ta a depth of.3 feet: Water table depot s !I <br /> I <br /> S£PTIC:TA#dK r �) Type/Mfq. I <br /> } Capacity No. Cnmlpartmante <br /> PKG. TREAT'MA&T PIT.O l .Method of Disposal 1 <br /> t i Distance to nearest: Wen Foundation Property Line <br /> le <br /> LEACHING LINE Not& Length of tines _ l �'Tnta! length/size <br /> FILTER BED --•O y Distarico tri.iiesisat; wellFoundation:_ r ~ perry Line <br /> :4 _ •Pro <br /> l SEEPAGE PITS is`Ooplh <br /> ��• Siza ,•, � 1 Number _ ] <br /> 4 SUMPS L; Disiance to nearest: 1Ve11.� s Fnura9atlan '� Progeny Lina ` I <br /> DISPOSAL PONDS C <br /> I hereby cerity that I have prepared this hpPlication and that the work will ba`dole in accordance with San Joaquinnd county ordinances, state taws, and <br /> rules aregulations of the San Joaquin,County - '-. r'- ^- <br /> HOme Owfw or licensed nt'9 - tl th ��✓ �", <br /> age signature tura certifies the fnilowing: "I certify that:yt the perfOTRlartt 8 Of the work fnt which this permit is sued, !shaft not <br /> employ any person in such manner as to.titrarrte subject to workman's co r-Pensauan laws of California."Contractor's hiring or sub-contracting signature <br /> cern#les the tolbwina:"l certify ttu!in the performance of the wars for which shin Derrnit is issued,:!shall amproy persons subJact to workman's compensa- <br /> tion laws of California.", N <br /> pocant roust cad for . rred i ctionti._COmpiete drawing on reverse side, l <br /> Signed X t Title----j `tyCy.-,.; f `. `Date: ? <br /> EPAflTMENT USE ONLY \. <br /> ,Application Accepted b ✓�-- l L'� t, <br /> Y _ AresPit rGrout Inspection bytit <br /> i- 742 <br /> Oats FinaiAnspection by e a Oats �f <br /> t fr <br /> -Additions/ Comments; <br /> APpllcant - Return all copies to. 'San Joaquin.County Public Health <br /> Servicer, D vironmental Health"Petait/Services <br /> 1401'E. U elton-Ave.. P 0 Boz 2009, Stockton, CA 95201 <br /> FEE MOiJt�T 011E " AMOUNT REMITTEDCK <br /> INF CASH 4 RECEiVE0.9Y OATt PEfltdiY'Ntl. <br /> • tH 15.7 iR(:V., n ai /l, .. <br /> v <br />