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�J. APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESR EC EV IV E <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 UP 3 0 1992 <br /> (209) 468-3447 ENVIRONMENTAL HEALTH <br /> YEAR PERM1115ERMLS <br /> (Complete in Triplicate) <br /> Application is hereby made_to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> applicatioa is made in comVliance with San Joaquin County Ordinance No. 51+9 and 1$62 and the Mules and Regulations of San <br /> Joaquin County Public Health services. C <br /> �1 C (J7 f City t Size/Acreage <br /> Job Address ,Q''+ • <br /> Phone <br /> Owner's Name Address <br /> reset/( a !–S5 ansa N Phone <br /> J <br /> COnlfactrvice Well <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L DESTRUCTION ❑ Out <br /> OF <br /> Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR tl I OTHER C1t <br /> DISPOSAL FLD.= ---,PROP..E:INE,�-- <br /> DISTANCE TO.NEAREST: SEPTIC TANK..-,T=_` --= ,SEWER LINES _ _--• <br /> ` <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Ind ❑ Open Bottum D Manteca Dia. of Well Excavation — 4 <br /> Specifications <br /> omestic/Private Cl Gravel Pack D Tracy Type of Casing, <br /> p Public <br /> Cl Other D Datta Depth of Grout Seal Type of Grout >` <br /> CI Irrigation Approx. Depth 0 Eastern Surface Seal installed by <br /> H <br /> Repair Work Done �7 Type of Pump •P• State Work Dane <br /> `– -- <br /> �______�_� <br /> Sealing Material i Depth <br /> Well Destruction a Well Diameter <br /> Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0...DESTRUCTION 0.lNo septic system permitted it public sewer is <br /> t available within 200 fee(.) <br /> installation will serve: Residence— Commerciat,!'• Other Y ' --t- <br /> Number of living units: _ Number of bedrooms <br /> Water table depth <br /> �- <br /> Character of soil to a depth of 3 feet: y <br /> A,. 1 <br /> SEPTIC TANK ❑ Type/Mfg <br /> r ,1 f "i Capacity-v r} No. Compartments <br /> PKG• TREATMENT PLT.Llr _ ' Method of Disposal <br /> Distance to nearest: Wog -+' Foundation =- Property Line ---- <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER'BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> `Sumps LI Distance to nearest: WeH Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify 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 regulations of the San Joaquin County <br /> Horne 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 any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the following:-I certify that in the performance of the work for which this permit is issued,i shall employ parsons subject to workman's compansa- <br /> tion laws of California," r <br /> The:Pplic& r all requir in ions. Complete drawing onre side, 9Signd Title: Date: <br /> � 11 <br /> DFic!ARTMENT USE ONLY <br /> Application Accepted by-=, ' -5;::�. _ Date Area <br /> Pit or Grovt Inspection by Date __._ Final Inspection by Date 7� <br /> Additional Comments: <br /> Appliee.nt - Return all copies to' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 B0 409, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE A AUNT RE MiTTEO CK* RECEIV D 8Y DATE PERMIT'N0. <br /> INFOI(NoI /L J-1 <br /> ' ENr344 f©(j4-51 <br /> EH 142E <br />