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k <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES } <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ATE 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 /> application is made in cottzipliance with Ban Joaquin County Ordinance No. $49 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address <br /> 1012 W. Yosemite City Manteca tot Size/Acreage .36 Acres <br /> Owner's Name Kenneth Hafer Address <br /> 232 N. Lincoln, Manteca, CA. Phone 823-3448 <br /> Contractor Consolidated Testi.n Address X055 W. Morton S C license rro.C57 544541 Phone (209) 781-0171 <br /> TYPE Of WELLIPUMP; NEW WELL E) WELL R PLACEMENT n DESTRUCTION Li WL of <br /> Well eqx <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST:, SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 17 i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4,r <br /> C1 Industrial © Open Bottom 13 Manteca Die. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing <br /> Sch. 40 PVC Specifications Flush Threadad <br /> 24.5' Type of Grout Neat Cement <br /> ❑ Public i'1 Other ©Delta Depth of Grout Seal ent nit R' <br /> G Irrigation —Approx. Depth O Eastern Surface Seal installed by Chem- rout Pump w tremie uirie <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> 4" scaling Material i Depot Bentonite ho <br /> 3e p_up ^ey�a <br /> Wall Destruction O Well Diameter #3 Sand ` <br /> Depth 40' Filler Material i Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-0 REPAIRIADOITION >:l DESTRUCTION G INeilable septic <br /> systithinem <br /> ranted it public sewer is i <br /> Installation will serve: Residence — Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feat: Water table depth � <br /> SEPTIC TANK ❑ Type/IMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 t Method of Disposal <br /> Distance to nearest: Well Foundation Property line <br /> LEACHING LINE C1 No. & Length of lines Total length/site <br /> FILTER BED Q Distance to nearest: Well Foundation — Property Line _ <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Property Line <br /> Well Foundation <br />' P <br /> DISPOSAL POthat <br /> ❑ <br /> I hereby ePO 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 /> Home owner or licensed agent's signature cenifies the following; "I camify 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 workmari'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 persons subject to workman's compensa- <br /> lion laws of California." <br /> The applicant cal for qulrad inspections. Complete drawing on reverse side. <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1 Date '' 10 4 r Area <br /> Data <br /> Pit or Grout Inspection by DatFinal Inspection by <br /> Date <br /> Additional Comments.- <br /> Applicant <br /> omments:Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 995 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH REGEtVE BY DATE PEAMIT N0. <br /> INFO c <br /> -ell <br /> EH t]•ZI If1EV.tubs UCS F> ; • �--rySJ <br />