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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL IiEALTH DI'V'ISION <br /> 1601 E HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOK 2009, STOCKTON, CA 95201 d, <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 /> application is made in compliance with San Joaquin County Ordinance No 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> Job Address Soos 'T-Ar, b City f"h<ly[dt .t,2 Lot Size/Acreage <br /> Owner s Name- / Q+i►9Vr�v c�oc+..r/ Address � &V,..r,% . 7$ Phone dT YG8 r2180 <br /> .r�5?a't itTd�� r' <br /> Contractor UP*% Addres$281 . 6-YA f -T— License No /.Z.2�»8 Phone �L <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION p Out of Service Well $ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Ora of Well Excavation Dia of Well Casing <br /> CI Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I I Public ( I Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Inrgat+on — Approx Depth 11 Eastern Surface Seal Installed by ' <br /> Repair Work Done 0 Type of Pump H P State Work Done _ <br /> Well Destruction JO Well Diameter j �iGl+•cq6 Sealing Material Depth <br /> Depth __/ Filler Material i Depth 7n O <br /> TYPE OF SEPTIC - sewer is <br /> Installation will <br /> Number of pill KLEINFELDER, INC 577 <br /> SACRAMENTO/ENVIRONMENTAL PETTY CASH <br /> Character of sc 3077 FITE CIR PH 916 366 1701 <br /> SEPTIC TANK SACRAM 0 CA 9 7 /7 19tt-49/12tp��� <br /> PKG TREATMEI PAY TO THE (� • ' <br /> ORDER OF $ <br /> LEACHING LINE DOLLARS <br /> FILTER BED n, `li Moun200Pt Diablo Pringle <br /> letoo NOT VA OVE $25000 <br /> 200 Pnnglc Avenue Suite r00 <br /> Walnut Cmek CA 94596-3570 <br /> SEEPAGE PITS Union Bank I <br /> 4 � , <br /> SUMPS MEMO ' <br /> DISPOSAL PON I: 12 L 000 4 9 71: 7 1L.0 L L 3 3 S 711' 0 5 '� 7 K �'' <br /> I hereby certify t tate laws and <br /> rules and regulat <br /> Home owner or licensed agent s signature certines the rorsowmg i i army alai ,,, ,„o F—,.,,., ui— v _ _-jed I shall not <br /> employ any person in such manner as to become subject to workman s compensation laws of California Contractors 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 /> non laws of California <br /> The appy ant m st call for all requ+redins ttons Complete drawing on reverse side ' <br /> g <br /> Signed }( _ TitleGjS� Date Z3 9L <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dale Area <br /> Pit or Grout Inspection by _ Dete Final Inspection by Date <br /> Additional Comments _ <br /> Applicant Return all coplea to San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E Hazelton Ave , P 0 Box 2009, Stockton, CA 9520 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY — DATE PERMIT NO <br /> Eli t324 i4Ev ,�+s <br /> EH 4 2p <br />