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" APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 14 <br /> ENVIRONMENTAL HEALTH DIVISION 5(tr <br /> P O BOX 2009, STOCKTON, CA 95201,_ <br /> (209) 468- 342D <br /> API, y1. 9 '1995 <br /> i <br /> (Complete 3n Triplicate) <br /> ENMONMENTAL HEALTH 1 <br /> k L1-111 CF ��i `FC <br /> Application 1s hereby ma.de,to Sa.a Joaquin County for a permit to construct and/or install thr ,voYkPhare nide c tied.: This <br /> appllcatioa is made in ccaplianca vith San Joaquin County Ordinance No: 549 and 186 and the Rulcs and Regulations of San l <br /> Joaqulo County Public Health Services. �I <br /> Idola, rl-Ir e cit, <br /> Job Address � r� Lot Size/Acreage �{[ <br /> Owner's Nam r Address L42Z i' <br /> 4+,• 0f' <br /> /��]]G/S I-�r�r,6rusca At v fK/�G� <br /> Contractor V Address _Aoiuyn, C.tiLQQ K74 Ell 79 License N0,15551 6 'Phone U <br /> TYPE OF WELLIPUMP: NEW WELL EC WELL REPLACEMENT (7' DESTRUCTION I❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ci OTHER i0 <br /> Monitoring Well IX <br /> K 2 <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES ACL�� DISPOSAL FLO. A2 "PROP*.• LINE 'J {i J^� <br /> FOUNDATION �O AGRICULTURE WELL � OTHER WELLN ._ <br /> / ;PITS/SUMPS Az,// i' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ' <br /> 11 Industrial ❑ Open Bottom C1 Manteca Die. of Well Excavation " Dia, of Well Casing <br /> VOomestic/Private JELGravel Pack ❑ Tracy Type of Casing "Specific a[ions <br /> '-�b-4�., � <br /> M Public 171 Olhor ❑ Delta Depth of Grout Seal SGl [ C Type of Grout-_Cr MPU l" } <br /> CI IrriUalion Approx. Depth ❑ Eastern Surface Seal Inslalled by f <br /> Repair Work Done {] Type of Pump M.P. I".State Work Done <br /> Well Destruction O - Wall Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth - sf <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIAIABOIT10N 0 DESTRUCTION ❑ (No seplic sysfem.permilted if public sdwe'r is <br /> / available within 200 feet.) <br /> Instillation will serve: Residence_„_ Commercial,,,,_ Other ° .11' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 9 feel: r _Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity—.—.: -No. Carnpar tmenis <br /> PKG. TREATMENT PLT.Gl Method;of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of linea _ Total length/size <br /> FILTER BED n Distance to nearest: Wall Foundation .� Property Liner' <br /> �•�. <br /> _ a <br /> SEEPAGE; PITS I I Depth Size Number <br /> SUMPS Ul Distance to nearest: Well Foundation Property.Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify that I have prepared this application and that the work will be dono 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 Certifies the following: "I certify that in the performance of the work for which this permit is issued, 1^shall not <br /> employ any person in such manner as to become #ubjact 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 persons subject to workman's compensa• <br /> tion laws of California <br /> The applicant t c I r all required inspections. Complete drawing on reverse side, a r <br /> g k <br /> Si nod Title: G77r � „ ,�r' Date:• 4 <br /> FOR DEPARTMENT USE ONLY, <br /> Application A copied by ` Data .Area + <br /> t e, <br /> Pit or Grout Inspection by Date a Final Inspection by Date �• <br /> Additlonal Comment#: <br /> l Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` <br /> 5�! 44IN SAN JOAQUIN. P 0 BOX 2009, SI <br /> 5TOCKTON, CA 95201 ^ <br /> i FEE AMOUNT DUE AMOUNT REMITTED K - 1 <br /> .w <br /> INFO CASHRECEI�VEDy�BV DATE PEaMlT'NO. f <br />