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f APPLICATION FOR PERMIT <br /> SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> o ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ' EXP RES 1 YEAR FROM DA IS,9UED <br /> (Complete in Triplicate) ' <br /> Applicat n'is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in•cotttpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County�Public Health Services. <br /> Job Address Cn City 4DC Lot Size/Acreage ZP -j <br /> Owner's Nam e C <br /> Addresses Phone <br /> Contracl'or <br /> Address_/_&rx !Y? & ab License No.d4E2Z_q_^1_0 Phonea•72 �7e?g <br /> r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑, Monitoring Well El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE` <br /> F FOUNDATION <br /> [ AGRICULTURE WELL OTHER <br /> WELL—PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE=CIFICATIONS <br /> Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> V1 Public fa Other 11 Delta Depth of Grout Seal <br /> ation Type o/ Grout <br /> I i Irri <br /> 0" —..Approx, Depth I I Eastern Surface Seal Installed by _ <br /> r Repair Work Done 0. Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth S.' (� <br /> _-• _ <br /> ..., ,S Depth "r; Filler Material b Depth <br /> TYPE OF SEPTIC WORK; . NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I INoseptic system permitted if public sewer is <br /> . available within 200 feet.) <br /> Installation will serve: Residence-V Commercial =Other <br /> Number of living units: Number of bedrooms'�3` A <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. - � • --Water-table-depth <br /> Type/Mfg l... Gc�r►cRer <�µ CI acity'ij(��_ No. Compartments <br /> PKG. TREATMENT PLT. Cl <br /> Distance to nearrest: Well <br /> ;,...._.� =.�_'-Method.of_Disposal <br /> dFoundation � <br /> �roperty, Line—lot <br /> LEACHING LINE �f - a <br /> No. & Length of lines _ O Total length/size <br /> FILTER BED C7 Distance to nearest: Well F <br /> 1 k-____. oundation_Z0 Property Line_lam j <br /> SEEPAGE PITS or Depth 1t Size..,.�(�_� Number 3 <br /> SUMPS LI Distance to nearest: Well �� <br /> -� Foundation ,42!" _,- Property Line /2>'DISP05AL PONDS ❑ . � ; <br /> ~ A 3 <br /> t 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 Joaquiri'County <br /> Home owner or licensed agent's signature certifies the following: 'JI certify that in the performance of the work for which this permit is issued, I shall n <br /> employ any person in such manner'as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance o}the work'for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.', <br /> Thefapplicant mus! call for all req ired inspections. Complete drawing o reverse everse side. <br /> Signed X 5 Title: j �� <br /> Date: 11� <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date ?0 <br /> M <br /> Area <br /> ►fi�or Grout inspection by Datez_t;Z, Final Inspection b <br /> Date <br /> Additional Comments; <br /> I: <br /> Applicant - Return all copies to: San Joaquin County Public Healthy <br /> —Services; EnvironmeritarHealth-p6tkdt/SiFf+vices <br /> 16o1 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED r CK q <br /> INFO' —/} CASH' a ;RECEIVED BY '_..DATE PERMIT'NO. <br /> ER f EK t4.2A IREV.r <br />