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Ile <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESAPR 15 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> .P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> (209) 468-3447 PERMIT/690' +G u <br /> f. pl"IT FMIRFS_ 1 YEAR VROM 12ATIJ ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby madt,to Snn Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made-in compliance with Ban Joaquin County Ordinance No. 549 and:1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address I cl 1211 jl�e City Tk—a_C:�I_ Lot Size/Acreage <br /> Owner's Name Address 7 d, Ze- Phone <br /> k. <br /> / <br /> Contractor JA Address License No 3. L Phone Z 79',.? <br /> 12, <br /> TYPE OF WELLIPUMP: NtEW WELL WELL REPLACEMENT DESTRUCTION ;kOut of Service well 5— <br /> , A, <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHEF 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 112V_' PROP. LINE <br /> �FOUNDATI.ONz,:---AGRICULTURE WELL OTHER WELL PITS/.SUMPS" <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C71 industrial 0 Open Bottom 0 Manteca Dis, of Well ExcavalLDia. of Well Casin <br /> .—.1— <br /> *Pomestic/Privaie Gravel Pack )(Tracy Type of Casing— Specifications <br /> , 1-1 Other Grout )2ZIz <br /> M Public 0 Delta Depth of Grout Seal Type of <br /> Depth 0 Eastern (2 <br /> M Inioalion -;�L5APPFO� Surface Seal Installed by <br /> A <br /> Repair Work Done 0 Type of PuTP H.P. State Work Done <br /> Material Ir Depth CZ i _/� 4" 0 <br /> Well Destruction Well Diameter X, a, - Sealing - - W t.J K_ 0 <br /> Depth Ie Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ED REPAIR I ADDITION 0 DESTRUCTION El (No septic system permitted if public sewer is <br /> available within 200 footA <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to 8 depth of 3 feet:t Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> —Distance to nearest; Well Foundation Property Line <br /> LEACHING LINE .0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation— Property Line <br /> ­-61S.—POSAL PONDS ­ 'o <br /> 1 hereby certify 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 /> Im Home owner or licensed agent's signature certifies the following: "I certify that in the periormance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to' 'become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> conifiss the following: 1 comity that in the poeofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Thepplicantrxiairtall for all r qLofed.inspoptions. Complete drawing on r afte Side. <br /> V i <br /> Signed X Date, Cl/ <br /> /FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Araa <br /> Pit or Grout inspection by ate Final Inspection by Date <br /> Additional Comments: r <br /> T <br /> Applicant - Return all copies to; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> C"4y 79— <br /> ti ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES - <br /> 445 X SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> INFO AMOUNT DUE i AmouNTREwrrto C 5 CK RECEIVED BY DATE PERMIT N0. <br /> COW <br /> EH 13-24 IREV,I/R51 41po <br /> [H 14-26 <br />