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i APPL I CATION FOR PERMIT D <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a <br /> } ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> I PERMIT EXPIRES 1 YEAR FROM DATEISSILII? <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. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> t Joaquin County Public Health Services. y-y� <br /> Job Address �l ria ��_ IeL.L�� F;ity e � of Size/Acreage <br /> Owner's Name -r�LL! �►YC- Address m Phone <br /> r Contractof��D�- , Address- ' License No. Phone <br /> -T— <br /> TYPE OF WELL/PUMP:-' -- "- -NEW-WELL' ""--WEL"L FIEPLACEMENT--D-'--"'- -DESTRUCTION- Out of-Service Well- -D <br /> `! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3Monitoring Well <br /> [' 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '�— DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 15-1 — OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fir <br /> H Industrial Open Bottom ❑ Manteca Dia. of Well Excavation f f .Dia. of Well Casing <br /> P Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I''l Public f 1 Other F1 Delta Depth of Grout Seal r Type of Grout <br /> I� Irrigation t00220'Approx. Depth I I Eastern Surface Seal Installed by Cjrl ---- <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 11 Well Diameter �� Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> t T OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it ewer.is, <br /> { available within 200 fee 1 <br /> Installation wi Residence— Commercial— Other ` <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fee . Water table depth <br /> SEPTIC TANK. ❑ Type/ C y No. Compartments <br /> I PKG. TREATMENT PLT Method of Disposal <br /> Distance to nearest: Well Foun Property Line <br /> LEACHING LINE CI No. & Length o ' as Total length Zl <br /> FILTER BED ❑ Distanc nearest: Well Foundation Property Line , <br /> # SEEPAGE PITS 1 <br /> Depth Size Number t <br /> SUMPS f:l Distance to nearest: Well Foundation PropetrtjL_ <br /> fel AL 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 /> j rules and regulations of the San Joaquin County �:, �1 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perfrrmancs of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 compensa- <br /> tion laws of California." <br /> f <br /> The applicant ust all for all r uired ' spections. Complete drawing on reverse side. <br /> � ��� <br /> Signed Title: �.( Date: <br /> i <br /> { FQR (DEPARTMENT USE ONLY <br /> r l Application Accepted by Date� y Area _ <br /> I, Pit or Grout Inspection �,Dat 7 Final inspection Date <br /> Additional Comments: - <br /> 14) <br /> t A licant - Return all copies to: an J �J ,{ <br /> " pp p Joaquin County Public Health Y,"-� <br /> Services, Environmental Health Permit/Services - a <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA. 95201 <br /> P CK A <br /> j <br /> INFO AMOUNT DUE ANJOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> : EH 13-241AEV.i/+s5� •Ny�. .l Y1f�­ <br /> EN 84.20 <br /> #i <br />