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1 � <br /> 1 <br /> APPLICATION FOR PERMIT i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <br /> ENVIRONMENTAL HEALTH DIVISION k <br /> P O BOX 2009, STOCKTON, CA 95201 t <br /> t (209) 468-3447 � <br /> .(Complete in Triplicate))J Sa_z3 <br /> Application is hersby scads to San Joaquin Count for a <br /> Application is bads in c y permit to construct and/or install the work herein described. This <br /> ompliance with Ban Joaquin County Ordinance Ito. 5119 and 1962 and the Rules and Regulations of San <br /> t Joaquin County Public Health Services, <br /> I ; <br /> Job Address 121 u2s E City Lot Slse/Acreage,OrX � <br /> 1 <br /> ;i Owners Name d �"- Address pd• �S� �"ftis, 9•5'2 -_-- Phone *06'T77 I <br /> Conuacltxs 'frti �[ or Address f License No.SIZ24aS Phone 'tl -57/2 <br /> f <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C7 DESTRUCTION p Out or service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES /Dor <br /> DISPOSAL FLDPROP. LINE } <br /> . <br /> FOUNDATION r 'I,� <br /> AGRICULTURE WELL .[!�[ — OTHER WELL ��� PITS/SUMPS <br /> INTENDED USE TYPE OF WEL.L PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> f.7 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Oia. of Well Casing ~ <br /> Domsatic/Private 67 Gravel Pack n Tracy Type of Casing PUL Specifications SC 14 0 <br /> D Public !a Other D Delta Depth of Grout Seat SLzttA Type of Grout Itdf Ph <br /> CJ IrriOation Approx. Depth C1 Eastern . Surface Ssul Installed by Ct-;H <br /> i Repair Work Done U Type of Pump H.P. State Work Done <br /> 1 Well Destruction 0 Won Diameter Sealing Material & Depth <br /> Depth_ biller Material"i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O�V REPAIR/ADDITION Ci DESTRUCTION G (No septic system permitted if public sews;isC; available within 200 feet,) <br /> InstsflaWn will serve: Residence— Commercial.—, Other <br /> Number of living units: Number of bedrooms <br />�. Character of sore to a depth of 3 test: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg CsPaci`IV No. Comparents <br /> PKG. TREATMENT PLT,C1tm ; <br /> l Method of DiWassl I <br /> Distance to nearest: Well Foundation - •_— Progeny Line <br /> i <br /> LEACHING LINE ❑ No. ti Length of lines Total length/si:e c <br />'s FILTER BED n Distance to nearest: Wall—�_ Foundation _ <br /> 4. P.ropeny line � <br /> SEEPAGE PITS 11 Depth Sires <br /> SUMPS - _ r Number •- <br /> LI Distance to nsarast: Well Foundation_ _ Property Line <br />$ DISPOSAL PONDS ❑ _ <br /> <" <br /> 3 , I 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 — I <br /> i rules and ragulalions of the San Joaquin County <br /> Homs owner to licensed agent's signature Cenifiss the following: "I certify that in the Performance of the work for which this Dermis is issued, 1 shill not LLJ <br /> employ any persoF <br /> ' n)n such manner as 10 become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br />` unifies the following:"I certify that in the pertormsnce of the worts for which this permit is issued. I shall employ persons subject to workman's compensate <br /> w <br /> tion laws Of iretifanla." U <br />{ i The spplieant mus a4 f r r ui inspections. Complete drawing on reverse side. I.LI <br /> I <br /> i Signed Title' t/t ` Dsq: Z-f30 c <br /> 4 FAR DEPARTMENT USE ONLY 9 <br /> Application Ac ted by �L3Date / d <br />}, Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> ditionat Comments: <br /> Applicant - Return all copies tot BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION pmWIT/SERVICES <br /> 445 H SAH JOAQUIN, P 0 BOX 2009, STUCXTON, CA 95201FEE 3Sd l <br /> i INFO AMOUNT DUE AMOUNT Mimi It RECEIVED BY <br /> CAS/1H ,�11 DATE PERMIT"N0. <br /> E;H 1�•I�1♦t EV.ri�sr � ^ � �:] 3L O <br />