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1 --� APPLICATION FOR ;PERHIT �# <br /> a . <br /> SAN .ZW QUIN COUNTY Pi]BLIC 4EA.LTH S&dICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> Y :FROld'.DATE <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to.construct and/or install the work herein described. Thii <br /> application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the 'Rules and Regulations of_San- <br /> Joaquin Colony Public Health Services. <br /> Job Address !.y ULi 0/G� hest• _ City r4G Lot Siie%Arrange <br /> Owner's Name �CLr f :- Na vG r Address /7S �• CLv e- <br /> ra Phone ,5��'p�bS <br /> Contractor G ddress ✓TLZ Lictrse No. 5,•z2'✓ ?hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION XOut of Service well. 0 <br /> PUMP INSTALLATION ❑ r SYSTEM REPAIR C? ' ' *r OTM R ❑- Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK k4 SEWER LINES > &Q6 ' AISPOSAL FLD, yA PROP. LINE 72-OOr <br /> FOUNDATION AGRICULTURE WELL N 14 OTHER WELL Sg r: PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' ,CONSTRUCTION SPECIFICATIONS N <br /> C� Industrial Cl Open Bottom' ❑ Manteca Oia. of Well Excavation - /0 Dia. of Well Casing <br /> U Domestic/Private C) Gravel Pack .>k Tracy -Type of Casing- y4 PUG "!-Specifications <br /> t ,I I Y1.4 <br /> Q Public ['I Other ❑ Delta Depth of Grout Seal Type of Grout& a.t <br /> CJ IrriUaiion [ App(os. Depth '0 Eastern Surface Seat Installed by - SA Cywt <br /> Repair Work Done ❑ Type of Pump <br /> H.P. Stara Work Pone <br /> Well 003t t, X Well Diameter Sealing Katerial &'Depth 0- 60 S <br /> Presse f0Depth Filler Natetial i Depth `\ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION C! DESTRUCTION C1 iNo septic system permitted if public sewer is C <br /> { available.within 200 feet.) r <br /> to:taliation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms (\` <br /> Character of soil to s depot of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.ClMethod of Disposal <br /> Distance to nearest: Well K Foundation Property Line <br /> LEACHING LINE ❑ Na. f!I Length of lines Total length/size <br /> FILTER BED I-] Distance to nearest: Well Foundation Propeny Line ' <br /> SEEPAGE PITS d:l I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line CJ <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> rules and regulations of the San Joaquin County ✓1\ <br /> Home owner or licensed agent's signature canities the following:' 'I certify that in the performance of the work for which this permit is issued, I shall <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hi ring of subcontracting signature <br /> certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i <br /> The applic m t tail for all req 'red ' s i s. Complete drawing on reverse side.. <br /> Signed Title: -/'rGYL � ,^ ,Date: Z 4 9 ' f <br /> FOR DEPARTMENT USE ONLY <br /> 00 <br /> Application Accepted by j OateArea 4�3 <br /> Pit or Grout Inspection by Date Final Inspection bS✓'t Data <br /> Additional Comments: _ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION P£RMIT/SERVICES i <br /> 445 N SAN JOAQUIN, P O BOX.,2009, STOCKTON, .CA 95201FE <br /> r <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE- PERMIT'NO. <br /> M• EN 13.24 iREV.I/KSI 1 , I� � 1 �� •— —�/ <br /> EI+,a26 d <br /> .l <br />