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APPLICATION
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH DIVISION.
<br /> 445 N SAN `JOAQUIN, PHONE (209)468-3420
<br /> P O BOX 2009; STOCKTON; CA 95201: -
<br /> -, PERMIT EXPIRES'-1 YEAR FROM DATE' ISSIIED''.;
<br /> s� fi Complete >`a Trlpiie te} r ,
<br /> i [ y.
<br /> dk
<br /> Application is hereby made,to San Joaquin County for a permit to construct and/or instep the Work.herein described This
<br /> application. is made in comPliance rrith'San Joaquin. County Ordinance No,. .549 and 1862,and the Rules- and'Regulations:of San
<br /> Joaquin County Public Health services.--
<br /> _ :.
<br /> Job Address Cit. Lo�'�.��Q t Size/Acreage
<br /> Owner's Name ddress- �Vl Phone-
<br /> 2 ~Z
<br /> w _
<br /> -,. ....._.- ...... r- '�fiO;:=I'�}G�.frl¢ License No.
<br /> 1,273-4`1'pane::,
<br /> Contractor 72 '3
<br /> �. ..-, TYPE-OF-WELL/PUMP NEW-WELL--pw:-. -_•WELL REPLACEMENT-0-..:_TE...-.. DESTRUCTION�Q_.Out_of;:,Service;.Wel .-.❑
<br /> " O
<br /> Monitoring Well
<br /> PUMP INSTALLATION © Y- SYSTEM REPAIR D -;
<br /> OTHER"
<br /> THER
<br /> pISTANCE.TO NEAREST SEPTIC TANK, SEWER LINES ,DISPOSAL FLD: PROP LINE''
<br /> FOUNDATION: AGRICULTURE WELL- f OTHER WELL S
<br /> PITS/SUMP
<br /> INTENDED USE `_ - TAPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS: y �
<br /> l _ E7 Indusirieli p.Open Bottom,. ' El.Manteca' Dia.of Well Excavation Dia of ell Casing h`
<br /> 3 { II -
<br /> Cl Domestic!Private ""p Gravel'Pack" " p,Tracy j TYPe ot`Casing t`' a Specificati=ns "
<br /> ° r'1'Publrc E 7 Other n. Delta c „ Depth of Grout Seal Type of Grout �
<br /> .....s
<br /> I(Irngation•' Jgz-f..Approx Depth' I Eastern i Surface Seal Installed by -
<br /> Repair Work:Done--C] Type.of Pump H.PF �. Stato Work.Done
<br /> Well Destruction, p. Well.Dlameterr Sealing Material !i Depth -
<br /> a q
<br /> y
<br /> y clePih" Filler Material is Depth..
<br /> TYPE OF SEPTIC WORK.--NEW--INSTALLATION I I• AEPA$R'/ADDITION t I DES RUCTION r`t INo septiasystem permitted ifi public sewer,is
<br /> availabie within 200 feet'.)_
<br /> "Instalrstion'wi serve Resijdence'_~' CommerciaF.:---Other
<br /> +w,Numtier ot;tx�riwms- ,:s I: � s
<br /> Number of ll+nng::untts.
<br /> Character-of Sod to a,depth'ofi3'feet ° r -'Water table depth
<br /> SEPTIC #_� Yype7Mfg Capatiry _ xE. t
<br /> No Compattntents
<br /> PKG.TREATMENT PLAT (� : ' " #_ , rw -^ h + A
<br /> x r * I . Method o[Disposal
<br /> AU
<br /> Dtstancet to nearest '" S well x �oundatlon F ProffBRy
<br /> i ._. ,. -. lll�ld,.. n..W.r,._ .. }.M _...?,.. .d..«_aw'_....-( ,rte,.. �yy_.'-", !r:w. _ .. r1. .,K•r i� ,< n..•
<br /> ! LEACHING LINE 0 A No &u Length of.fines $ Total.Iength/size % I s.s� r*
<br /> FILTER BED © Distance to nearest r WeII iFoundatron d Property Line .�s
<br /> ...:...... d I x V r 'd
<br /> SEEPAGE-PITS ' E 1. Depth Size i Number 5 UNT = '.
<br /> .
<br /> K
<br /> SUMPS ' Ll tDistance to nearest F well Foundation Property Lin �T` ICE ,
<br /> pISPOSAk'PONDS" s-.,.Or -t ,. -• ,-. ..- v. �. ..�--� _ .._ ,
<br /> I hereby.certify.that_I have prepared-this.application and.that:the.work will be-done ire,accordance with San Joaquin county ordinances ata--laws and
<br /> ruies-and regulations of the San Joaquin-County, r 'performance.
<br /> Home,owner:or licensed agent'is.aignature certifies the following:,9 certify thatcin-the performance.ofthe.work-forwhich,this permit is Issuer f4ahell not
<br /> employ any person in such manner as to become subject to workman's compensation laws of California."'Contractors hiring or issued, to'sub-contracti'ng:signature
<br /> certifies the following:"I cavity-tharin the performance of the work.for which this permit is issued, I shelf employ persons subject workman'i compansa-
<br /> tion laws of California." ' rt
<br /> i,
<br /> -The applicant i calf requir in na:'Complete drawing-on reverse side. �y
<br /> Signed'_ - Title:-- }�YY1G /'!d Date:
<br /> .._,..FOR DEPARTMENT USE.ONLY
<br /> 1 3 Area��+C,.ZG
<br /> Applicatlon'Aceepted by Date v —^�
<br /> Pit or Grout Inspection by ate. Final In by Date
<br /> Additional Comments: / r
<br /> Applicant - Return. all copies to: Sass Joaquin County Public Health Services 1��• tJ,i.�
<br /> EnvironmentalHealth Permit/Services
<br /> 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201
<br /> IN O ��AffM��OUNT DUE AMOUNT REMITTEDA5H RECEIVED BY DATE PERMIT-NO.
<br /> 4 EH M24 IREV.s/at 51 •7' VI Y
<br /> FN 11.26 - -.___— 111JJJ
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