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r <br /> fi <br /> , e APPLICATION FOR PERMIT <br /> ,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 6 ENVIRONMENTAL 'HEALTH DIVISION <br /> r, P 0 BOX 2009 `_$TO KTON, CA 95201 <br /> (209) 468-3447 <br /> 21MIT EXPIRES 1 YTAR FROG DATE 7 SSUED <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 cc=pliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _Z 0032 �� 4b. S Cit t Site/Acreage <br /> Owner's Name AyjQ J1 LJ Q I 1 &CU.Q d d Address I -3 • r Phone 9t1 _apy/ <br /> contractor h_e.L&� [t Address . ! _ o {Z 1-_____ License No. C.IIe 3 73 Phone <br /> TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION '❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well- L� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fJ Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing Specifications <br /> ❑ Public I"'I Other ❑ Delta Depth of Grout Seal Type of Grout <br /> EJ Irriontion Appror, Depth 0 Eastern Surface Seal Installed by n` <br /> Repair Work Done Ur""Type of Pump sC&A H.P, __ State Work Done_ �] <br /> - --- -�Fkali lJnterial i�D t ham. (� <br /> Weil Destruction O Well Diameter" <br /> "Y <br /> Depth Filler Material i Depth ILq.I' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOITION Cl DESTRUCTION G (No septic system permitted it public sewer is <br /> avail a within 200 feet.) <br /> Installation will-serve: Residence.^I Commercial Other <br /> Number of living units: Number of bedrooms <br /> r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑- Type/Mfg Capacity No. Compartments '! <br /> PKG. TREATMENT PLT. Cl ! s Method of Disposal <br /> Distance to knearest, Well ndati Property Line rn <br /> l6 <br /> LEACHING LINE C1 No. B Length of lines Total length/size <br /> FILTER BED (1 Distance to inearast: WeltFoundatio Property Lina <br /> SEEPAGE PITS IJ Depth Size Number <br /> SUMPS LI Distance to nearest- Well Foundation Property Line <br /> DISPOSAL PONOS 0 <br /> I hereby certify that I have prepared this application d that the work will be done in accordance with an Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or I' a nt's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any son in such neer as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies th ollowing: "I carofy that in the pe rmance of o for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws f Caiiforn <br /> The ap )cant mus or require tar a draw g an re :e side. <br /> Signed ilia: �ifil/C Date:`/CO r � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data ea f <br /> Pit or Grout Inspection by __ —.Date Final inspection by Date <br /> ZLO <br /> ] F <br /> Additional Comments: �_+ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 95201 <br /> FEEf <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH^ RECEIVED 8y DATE PERMIT'N0. <br /> f <br /> + EH 11.24 IlIEV.I/"$) <br /> fi <br /> /i <br /> 14 <br />