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T • APPLICATION FOR PERMIT • <br /> lip SAN 'Jot, <br /> , N COUNTY PUBLIC HEALTH SERVICES �� I <br /> /liN IRONYENTAL HEALTH DIVISION <br /> 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES I YEAR PROP DATE ISSUED <br /> ') � (Complete 1n Triplicate) <br /> Application Is hereby made to San Q n County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San JwQYln County Ordinance No. 5 and 1 62 and Lh Rulea and Regulations of San <br /> Joaquin Coll��jj��y ib ea 8erv1 ea l t,{/Cl (�LT/C/i <br /> r ,ph� �01 1—Q� B Ally l�fA-Ar p X1a <br /> Job Add( "� '�� City � Lot Size/Acreage <br /> Owner's Name Y `/ �f/yI Address Freyr&_ <br /> �'�"'� Phone s� <br /> Contractor e!� d J'sSe Address�'•� F,w Tr &_ License No.GItX9 Phone -i3YJ <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER)< Mon1torl Wel} <br /> 5 1�+1s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FMD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS dee <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 r F• �. <br /> 1.1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domesbo/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal T a I Grout (00 t� <br /> M Irr.galion —.Approx. Depth 0 Eastern Surface Seel Installed by IN <br /> Repair Work Done U Type of Pump H.P. State Work Dona __ I <br /> Will Destruction ❑ Well Diameter Sealing Material 4 Depth L2AYz <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI INo septic system permitted it public sower is <br /> available within 200 feet.) <br /> Installation will serve Residence_ Commercial _ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Companments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> SUMPS �LI Distonce to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I hove 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 /> Home owner or licensed agent's signature conifies 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 compensationlaws 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&hall employ persons subject to workmen's compensa. <br /> tionlaws of Celilo/rn1111." <br /> The applicant requir i s Complete drawing o(nhl{sverse tido. <br /> Signed X_� C „ Title: ii r0i �v1��1-fh Date: af✓ 1/ <br /> Ofl EPARTMENT USE ONLY <br /> Application Accepted by -� O ,PCJ Data Area J <br /> Pit or Grout Inspection by Date Final Inspection by—21Dater <br /> Additional Comments: _ ��� �i/4r1�1� L-'114112 M12J' yf/a �C, enY <br /> Applicant - Return all copies to; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> t IAMO(UyNT DUE AMOLINT REMITTEp CA H RECEIVED BV D7ATE9 PERMIT NO <br /> EH1124IaEv i'+e,[:FEE <br /> ]r - �'JQ 1 91- a <br /> EH u.m (l <br />