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O &5) V7K 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 />PERMIT EXPIRES 1 YEAR PROM DATE ISSUED <br />(Complete i❑ Triplicate) o Z3 <br />Application is hereby made,to San Joaquin County for a permit to construct aARA) <br />nd/or install the work herein described. This <br />application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />Job Address _1211 11.x. Fre nir34 ' Sf, City4jjK]!G'ft, 1 Lot S1ze/AcreageOb X IS, <br />Owner's Name _G"e <br />L&A,G% Address 9d-j3dx <br />081 S-fet-K ,:w CIS'2a 1 Phone AP& sf 9 7 1 <br />ConlractorSCfYUM <br />T dY d Address & <br />e !` License NO: 1Z2.(2E-", Phone -S71Z <br />TYPE OF WELL/PUMP: <br />NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well Cl <br />PUMP INSTALLATION O <br />SYSTEM REPAIR O OTHER O Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANKx(14 SEWER LINES <br />%©O' DISPOSAL FLD.-IYA PROP. LINE <br />] <br />FOUNDATION �!?r AGRICULTURE WELL ,L&-_ OTHER WELLNIA PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />0 Industrial <br />O Open Bottom ❑ Manteca <br />Dia. of Well Excavation 10 4" Dia. of Well Casing 4r <br />%Domestic/Private .' <br />0 Gravel Pack O Trac V <br />T PLIC SCH ¢D <br />Type of Casing Specifications <br />ID Public <br />I:l Other Delta <br />O <br />Depth of Grout Seal c+2r. Type ype of Grout CGLtf PH l+ <br />S. <br />C7 Irnoation <br />�Approx. Depth ❑ Eastern <br />_ <br />Surface Seal Installud by CG�I�C ti's/ <br />Repair Work Done U <br />Type of Pump H. P. <br />State Work Done _ <br />Wall Destruction O <br />Well Diameter Sealing Material i Depth <br />Depth Piller Material L Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION Cl DESTRUCTION G (No septic system permitted it public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence _ Commercial _ Other <br />Number of living units: <br />Number of bedrooms <br />Character of $011.10 a depth of 3 feel: <br />Water table depth <br />SEPTIC TANK <br />O Type/Mfg <br />Capacity No. Companments <br />PKG. TREATMENT PLT, <br />Q <br />Method of Disposal <br />Distance to nearest: Well <br />Foundation Property Line <br />LEACHING LINE <br />Cl No. b Length of lines <br />_ Total length/size <br />FILTER BED <br />0 Distance to nearest: Well <br />Foundation ._ Propeny Line <br />SEEPAGE PITS <br />11 Depth Size <br />Number <br />SUMPS <br />LI Distance to nearest: Well <br />Foundation Propeny Line <br />DISPOSAL PONDS <br />O <br />"Gravy csrmy inar r 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 Sen Joaquin County <br />Home owner or licensed agent's signature cenifies the following: "I certify 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 workmen's compensation taws of California." Contractor's hiring or subcontracting signature <br />certifies the following: "I cenify 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 . m t call all re re inspections. Complete drawing on reverse side. <br />Signed ' Title: S S�Y1561 Vl 1 Date: ! Z�3�� lq3 <br />FOR DEPARTMENT USE ONLY / <br />Application Accepted by Data % C Area <br />Pit or Grout Inspection by 7 Date Final Inspection by <br />Additional Comments: <br />Applicant —Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />pO\ <br />U� 13-211REV. r/MS <br />CH ;1.1y <br />Date <br />ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br />445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br />FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br />INFO CASH DATE PERM17 N0. <br />0�510 "AL i 10 % 'ge; ?ZU <br />