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APPLICATION FOR PERMIT <br /> T� <br /> SAN JOAQUIN COUNTY PUBLIC ,4EALTH SERVICES <br /> ENVIROffWtNTALNHEALT1 DIVISION <br /> ' a P O BOX 2009; '3TOCgTOI+i, CA 95201 <br /> (209) 468-3447 <br /> YEAR PROM DAIE ISSUED <br /> 1 Wim' J �OrnS.�C (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 /> application is made in corapllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> • Joaquin County Public Health Services. <br /> .... <br /> Job Address atl= 1 City ikadvA61LIt Sine/Acreage <br /> r " <br /> 1 Owner's Name _cI� i ,1d tfl_ rnQ..n 1 nrrens Phone Q Sol-6 b 8`0 <br /> Contractor -�^s �.{MA Addres0 OAC i G LicenseiNo. �bz3'f3� Phone <br /> TYPE OF WELL/PUMP: s' NEW WELL O WELL REPLACEMENT 177 DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0--' .. OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1.7 Industrial ❑{Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑Provel Pack ❑ Tracy Type of Casing Specifications <br /> M Pu lie n biher ' ❑ Delta Depth of Grout Seal Type of Grout <br />{ rrrgaIi0n _;�74prox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done LS Typs of Pump � T H:P, D State Work Done Klebw Id To 3 C) <br /> Well Destruction 0 We('Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION Cf DESTRUCTION G (No septic system permitted if public sewer is <br /> �t available within 200 feet.) <br /> Installation will serve: -Residence Commercial— Other <br /> Number of living units: Number of bedrooms t <br /> Character of )roil to a depth of 3 feel: Water table depth I <br /> SEPTIC TANK. O Type/Mfg X <br /> No. Compartments <br /> PKG. TREATMENT PLT. C) f: fMethod of Disposal <br /> Distance to nearest: '-Well s <br /> �- r � Property Lina <br /> LEACHING LINE Cl No. & Length of lines '� /i is t.�. <br /> FILTER BED n Distance to nes est: Well <br /> � Property Line � J <br /> { •d <br /> SEEPAGE PITS IJ Depth "r` <br /> -Size /- <br /> Num r <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O id t <br /> -_.�I hereby-cartify_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 regulation San Joaquin County ', y `4 <br /> Home owner ar ' nsed ag nt's signature Certifies thsjof tiowing�l cert'ifythat in the perl6rmance of the work for which this permit'ii issued, I shall not <br /> employ any on in such neer as to come 6 , t t'o workman's compensation laws of California," Contractor's hiring of sutifibntracting signature <br /> certifies the lowing: "I c 'fy that i r nc of the work for which this permit is issued. I shall employ persons subject to workman's compensa- <br /> tion laws Califo is." <br /> The appl' an ail r all re Cam I drawing an v *,do. <br /> Signed Title; ��fJJ�6/J Date: .� <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by 5 J <br /> ' ,Data — � Area r <br /> Pit or Grout Inspection b I <br /> Y Date Final Inspection by - _ Date~ 7 r <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> - ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOJ) 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DuE AMOUNT REMrTTED <br /> INFO `CK ` RECEIVED 8Y' <br /> _ CASH DATE-, <br /> PERMrT'NO. <br /> EEHH 13.24 1REV. 1 <br /> 74.26 fff f� D$ i+ Ln <br />