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h <br /> h�®�� <br /> a/v `r" APPLICATION <br /> r, --lass <br /> !a7e <br /> M 3$ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> !��-���• 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> .Application is hereby made to San.Joaquin County for a permit to construct and/or install the work herein described. This <br /> aad <br /> application is.me in compliance with San Joaquin County Ordinance No. 5h9 e'nd 1862 and the Rules and Regulations of San <br /> ,.Joaquin County Public°Health Services. n <br /> Job Address <br /> 28981. : S . . CHR•ISMAN RD. ci,y TRACY Lot Size/Acreage <br /> CURTIS NELSON <br /> Owner's Name NELLIE BARETTA Address 28989 S . CHRISMAN RD. Phone578-1504 <br /> Contractor HENNINGS BROS. DRILL�ddress 3525 PELANDALE AVE. M01053a516vo. 290813 Phone 545-1185 <br /> TYPE OF WELL/PUMP: NEW WELLH WELL REPLACEMENT i-1 DESTRUCTION Ll out of service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK 10 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL--2-SQ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing a� <br /> )H(Oomestic/Private M Gravel Pack IX Tracy Type of 'Casing_ P V C Specifications- 16 0 S CL— V <br /> ['1 Public f-1 Other n Delta Depth of Grout Seal 100 Type of Grout BENTONITE <br /> I I Irrigation r,Approx. Depth I I Eastern Surface Seal Installed by H E N N I N G S B R O S.DRILLING CO. <br /> Repair Work Done L] Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth <br /> Depth Filler Material 8 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 /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, M Method of Disposal <br /> Distance to nearest: ' Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 4 r <br /> rules and regulations of the San Joaquin County �✓ <br /> Home 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 whibh this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applit must call for all required inspections: Complete drawin on reverse\si�a. <br /> Signed g Ie: 't`1 _ Date: JUNE 23 , 1993 <br /> O _MENT USE ONLY <br /> Application Accepted bye.._ N14,+if ,jysa Date C11— <br /> Area <br /> Pit or Grout Ins 4 <br /> Inspection by Date ,Final Inspection by � Dets <br /> 'r <br /> Additional.Comments: ' <br /> Applicant Retu all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> - 445 N San Joaquin, P 0 Dox 2009, Stkn, CA 95201 <br /> INFO <br /> FEE AMOUNT OVE AMOUNT.REMITTED CASH RECEIVED BY GATE PERMIT'NO. <br /> EK V. <br /> lr.1 <br /> EH /NS1 1� t �� ,'^� 10.J �a �1�•� ��� <br />