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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-8420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PgMIJ EXPIRES 2 YEAR FROM DAIE 15SUED <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 1$62 and the Rules and Regulations of San <br />` Joaquin County Public Health Services. <br /> r Job Address .2 1" // <br /> City Lot_Size/Acres e <br />' Owner's Name /`1raC�N���/JV Address _/Zj y"a s"� Phone <br /> Contractor 41�. - � Address &D.GgdD'Kdd F?. . _ License No. Phone �- <br /> TYPE OF WELL/PUMP:,,,..,.,,_.,._ NEW WELL_❑_..._ _.,;,,WELL REPLACEMENT..❑.-.—DESTRUCTION.❑.Out of Service Well ❑ <br /> PUMPt INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑ Monitores$iWe11�t�F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNOATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial C] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public CI Other it 1­1 Delta Depth of Grout Seal Type of Grout <br /> IlI I Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ Vf <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l (No septic system permitted if public sewer is <br /> I ! available within 200 feet.) <br /> Installation will serve: Residence r Commercial— Other <br /> 1 Number of living units: .Number of bedrooms_- 2 <br /> I Character of soil to a depth of i feet: Water table depth <br /> SEPTIC TANK Type/Mfg 'LZ,,ZFC Capacity �'Lyy No. Compartments 2L, <br /> PKG. TREATMENT PLT. ❑ Method of Disposal h <br /> Distance to nearest: Well _�` Foundation S Property Line X 4 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest. Well Foundation_ Property Line <br /> A .. <br /> SEEPAGE PITS 1 1 - Depth Size Numberl <br /> SUMPS LI Distance to nearest: Well ! Foundation T Prbperty Line <br /> DISPOSAL PONDS ❑ L <br /> I hereby certify that I have prepared this application and that the:work willbe done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County j <br />` Home owner or licensed agent's signature certifies the following:1 I cart that in the performance of the work for which this permit is issued, I shall not <br /> fl 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 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 /> The applicant must call for al required inspections. Complete drawing on reverse side, <br /> Signed X Title: __qa.1t. _ Date: <br /> USE ONLY <br /> Application Accepted by Im CS Date ~ l Area <br /> Pit or Grout Inspection by Date Fine Inspection by Date_7V QE7 <br /> I <br /> 1 Additional Comments: f <br /> Applicant - Return all copies to: San Joaquin ounty Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> k <br /> r <br /> IEEE {A 1M rO-U}NTsfDUE AMOUNT REMITTED �ASp RECEIVED BY 7 DATE PERMIT'NNO'.{� <br /> . EH 13.24 trIEV.,i n sl 1 1 1 , V t� r C�� �'C7 f e / 4 4f o o � w• V <br /> EH 11.20 <br />