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APPLICATION' FOR PERMIT <br /> ` SAN JOAQUIN C0uNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (Complete in Triplicate) <br /> Application is hereby arads.to San JoetyuLn County for a permit to construct and/or 1nata11 the work ktreitt described. This <br /> Application is made in cOmPliaoee vith Sats Joaquin County Ordinance No. 549 and 186.1 and the Aides and Regulatiana of San <br /> Joaquin County Public Health Services. <br /> Jab Address 154Mf E40 wnA- AI-� City LOT) Lot Site/Acreace := 110 c.t.na s <br /> Qwner'aNama S _1viC, Address �«of _ Ls+.�•t Pltane Z0 333-0 35 <br /> PZ. 'Cie+A I"f C—$7 <br /> Contractor Address_ /�—�+- � gl License No. S�Z198 Phone b I6 -3 -if f! <br /> TYPE OF WELL/PUMP: NEW WELL 29 WELL REPLACEMENT ❑ DESTRUCTION ❑Out of Service We11 [] <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3 Monitoring xel.lj <br /> DISTANCE TO NEAREST: SEPTIC TANK -ZG :&- SEWER LINES DISPOSAL FLD.!V,4 _.PROP.LINE <br /> FOUNDATION _AGRICULTURE WELL(.OTHER WELL j:4:= PITS/SUMPS &V& <br /> y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I L7 Industrial ❑Open Sonant ❑Manteca C:e.of Wall Excavationr�M4 Dia.of Woo Casing <br /> 4 r' <br /> [l Damastie/PrivateKGraval Pack ❑Tracy Type of Caning_- r. Ste. 40 P►rC Sptcifuatxatt <br /> I'l Public 1.1 Other F1 Delta Depth of Grou;Sealer Type of Grout <br /> I I i Irrrgarion <br /> —Approx. Depth 112astern Surf ca Seal Irattllsd by _T ,4 ¢� ✓r <br /> Repair Work Done 113 Type of Pump ��_ H.P. Aj Stat Work 1Jorrs. ' <br /> i <br /> Well Destruction C3 Wall Dia w!w m <br /> • ag Ma rial i 11"30 i a✓�+-s d vrrr;y��n <br /> Depth_ -_ 60 F+_ Filler Hsae-tarial i Depth Ak AAS. : t� ]�"""" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> i available within 200 fmi.l VP <br /> Installano servo: Residence_ Commercial_ Other <br /> Number Of living Number of bedrooms <br /> Character of sail to s depth o Wag depth <br /> I SEPTIC TANK ❑ Typo/M119 Capacity No.Comp inments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> € i Distance to nearest: Well n Property Line_— <br /> t 3 <br /> LEACHING LINE ❑ No.&Length s . Tela th/sits <br /> ¢ FILTER BED ❑ Dista o nearest: Wet! Foundation— Pre <br /> i.r SEEPAGE PITS I 1 Depth _ Sire Nurnbw <br /> I SUMP LI Distance to purest: Well Foundation Property Lina <br /> .i OSALPONDS ❑ <br /> 1 hereby certify that?have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state lauy,and <br /> rules and regulations of the San Joaquin County <br /> r Home owner or licsnanl agent's signature canities the following:••I certify that in the performance of the work for which this Pamir is issued.I shell not <br /> - i employ any person in such manner as td bseome sublact to workman's compensation laws of California."Contractoes hiring or sub-contracting signature <br /> t certifies the fdilawing:"I certify that in the performance of the work for which this permit is issued.I shall employ persons sublect to workman's compansa- <br /> tion laws of Caldemis.' <br /> Th eppli- m li far el r]equrr n Campleq drawing an reverse side. <br /> ,,.. <br /> S ned4 tan[ n t vG!J <br /> Title: Date: 1 Y Oc, <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Ana <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> dditionel Comments: <br /> i Applicant Return s]l copies to: San Joaquin County.Public Health <br /> 5arvices, Enviromments.1 Health Permit/Services <br /> 1601 E. Hazelton Aye., P 0 Bax 2949, Stockton. CA 95201 <br /> FEE <br /> 1NFOAMOVNT.OLE AMOUNT REtittTTED .CASH RECEIVED BY HATE - PERMIT'N0. _ <br /> En 17.24(NIV.10.so - - <br />