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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � � far <br /> ENVIRONMENTAL HEALTH DIVISION f: . <br /> 1601 E. HAZELTON AVE. , PHONE (209)468V 4D "� <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> JUN 2 4X991 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I <br /> (Complete in Triplicate) �N ONNI NT�� <br /> hERM IT f SERV I= -- <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install e 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 /> Joaquin County Public Health Services. <br /> &9Job Addresst _Aj arity CWVLot Size/Acreage <br /> Owner's Nam4 <br /> Al <br /> Co tr Kqe: l� Phone / ! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ y WELL REPLACEMENT C.:1 DESTRUCTION ❑ Out of Service Well C7 <br /> PUMP INSTALLATION iSYSTEM REPAIR 0 OTHER ❑ Monitoring Well Ca <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `- <br /> ❑ Ipdustrisl—, ❑ Open Bottom, C] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> gmesticL Private" —70 Gravel Pack.d. `��_}'b.Tracy Type of Casing_ Specifications <br /> 1"1 Public �`—"^"'I:1 OtFier'' �-v Fl.Delta" Depth of Grout Seal Type of Grout <br /> I i lrriUation _Approx. Dept I I st '►n S rface S al Installed by <br /> Repair Work-Done, 0 Type of Pump H.Pr State Work Dan <br /> Well Destruction 0 Well Diamet r Sealing MaArial & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC-WORK:, NEW INSTALLATION I 1 REPAIR/.ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> #+ available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> f V <br /> Number of living units: Number of bedrooms - <br /> Character of soil to a depth of 3 feet: Water table depth t <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal .. <br /> Distance to nearest: Well Foundation Property Line <br /> I� <br /> LEACHING LINE 0 No, 8 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest:. Wall..- Foundation Property Line <br /> SEEPAGE PITS I I Depth A# Size <br /> Number <br /> SUMPS LI Distance to neerest."ll: Well Foundation Property Line <br /> D15POSAL POfJDS Q----_--- -_ <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 \ <br /> Home owner or licensed agent's signature cenifios 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 rtify 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 <br /> Ii nt st call r I requi d inspe. tionl, mplete drawing on r ers si <br /> Si n <br /> g Ti Date: (;;A)A <br /> OR D PARTMENT USE ONLY <br /> Application Accepted by Date � t7U Area <br /> Pit or Grout Inspection byDate Final Inspection by Date <br /> Additional Comments: <br /> Applicant Return all copies to: San Joaquin County Public Health i <br /> Services, Environmental Health Permit/Services ` <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 f <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CAga{ DATE PERMIT'NO. <br /> + EH 13-24{NEM-V A 5) y, t!�-� - mop . <br /> EH 14-2e f v i <br />