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L ' <br /> AFPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC i1EA S SERVIC <br /> EN V I RON1dENTAL }iEALT$ DIVISION jj u <br /> P 0 80X .2009, STOCKTON, CA :95201 <br /> (209) 468- .3,420. - <br /> FEB 1 11992 <br /> PERMIT EXPIRES 1 YEAR PRQ9 PATE ISSUJW <br /> E (Complete in Triplicate) ENMRONMENTALHEALTH <br /> Application to hereby made,to San Joaquin County for a permit to construct and/or install th� ��td4cribed. This <br /> application is made in compliance with Sats Joaquin County Ordinance Ho. 51x9 and 1$62 and Lha Rules an egu tiona of San <br /> 1 Joaquin County Public Health Services. <br /> Job Address 2 9lv �� ��� City'5rG2L-7_0L _ Lot Size/Acreage { .S-AC ± <br /> Owner's Name JOH1) MARC Address Zg73 4=0&15 2A- STr2Cc7-Crt� Phone.g4160"06-1¢ <br /> Contractors Address 25z5Dt',MYeTt_f 57- _ License No.6122&6 Phone4&•5-871Z <br /> TYPE OF WELL)PUMP: NEW WELL Q' WELL REPLACEMENT F] DESTRUCTION CI Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK f50= SEWER LINES �7_t DISPOSAL FLD. PROP. LINE Zt�_ <br /> FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> j M Industrial ❑ Open Bottom ❑ Manleca Dia. of Well Excavation " Dia. of Well Casing 2 A i " <br /> Domestic/Private q Gravel Pack CJ Tracy Type of Casing 20c SpeciticationsSCA 44 <br /> Public I.1 Other © Delta Depth of Grout Saal SuRFAcf Type of Grout <br /> CJ trriUation D' Approx; Depth © Eastern Surface Soul Installed by s-Pi=_CM,Z fCy_r>L,0fj- <br /> Repair Work Done Ll Type of Pump fi.P. Slate Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION Cl DESTRUCTION CI INo sopdc system permitted if public sawar is <br /> availablo within 200 fast.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK. O Type/Mtg Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to noarast: Well Foundation _ Property Line <br /> LEACHING LINE Cl No. 6 Length of lines _ rola) longth/size <br /> FILTER BED 11 Distance to nearest: Well Foundation Propeny Line <br /> SEEPAGE PITS . l 1 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 naraby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> +ulos and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies 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 workman's compensation laws of California." Contractor's 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 componsa. <br /> tion laws of California." <br /> The applica t must GJ01 for al re��insni;. Complete drawing on reverse side. <br /> Signed Title: —eO)V'5Uc.-r .V T1 Date: /-eh, 7 1,J9'Z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b --✓l Dale �r Area <br /> Pit or Grout Inspection by r Data Final Inspection by Data <br /> Additlonal,Comments: o <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> } ENVIRONMENTAL HEALTH 01VISION PERMIT/SERVICES <br /> 495 N SAN JOAQUIN, P 0 UOX 2009, STUCKTON, CA 95201 <br /> INFO AMOUNT DUE, AMOUNT REMITTED C x 9 RECEIVED ay DATE PERMIT NO. <br /> 0 t <br /> Eli I3-74 tnEV.rix$1 9 s:t �� 7T 1 i6r p. <br />