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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED <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 i <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 /> I Li 194 f� C)a AJ-cb, �. I <br /> Job Address _ + City Lot Size/Acreage <br /> t L� � <br /> Owner's Name , 1"6!r_ Address ` 4 1 ® Nr DCT.04'b.0<XiCr Phone <br /> 'Po x)07 6 ! .crdi 3a�a�(0 '��-SO <br /> Contract ddress License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well/.0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well rC� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .v <br /> n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications <br /> F) Public Cl Other n Delta Depth of Grout Seal Type of Grout- <br /> -I I Irrigation _.Approx. Depth I I Eastern Surface Seal installed by s <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ' <br /> Well Destruction ❑ Well Diameter 4Sealing_Material-&_Depth <br /> Depth kFiller Material & Depth t ! Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I QEPAIIADDITION,.iA7rDESTRUCTION I I IN&- eptic system permitted it"public sewer is <br /> § available within 200 feet.1 \� <br /> Installation-will serve: Residence Commercial_ Other <br /> ti--Numberof living-units:---L---Number-o drooms �` 1 <br /> Character of soil to a depth of 3 feet: 8 Water (able depth <br /> t <br /> ', SEPTIC TANK. �, ❑ Type/Mfg capacity---- / No. Compartments i <br /> PKG. TREATMENT PLT.f❑ �'r r l ' � Method of Disposal ; <br /> Distance to nearest: Well ...Foundation Pro/perty Line i <br /> LEACHING LINE ❑ No. & Length of lines Total length%size <br /> FILTER BED n Distance to nearest: Wall 'Foundation 1 Property Line <br /> SEEPAGE PITS l I Depth' ��51 Size x— L1T,Number ` <br /> T � + <br /> SUMPS � Distance to nearest: Well 100' Foundation t�� Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 V� <br /> rules and regulations of the San Joaquin County "'''•.k �,.,.��;,/ ' h �' 11:> � <br /> _Home.owner or licensed agent's-signature.carlifies the fotlowingr,"I ceitify 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 work"mah'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 fbrrvhich_''his permit is issued;'f shall employ peisorta subject to workman's compensa- (( <br /> tion laws of California..' i .!J*' <br /> The applicant t call for Vuir d inspections. Complete drawing on rdvef"'si e. r v <br /> Signed t _... <br /> g Title: r Date <br /> 1 <br /> FQA DEPARTMENT USE ONLY <br /> Application_Accepted by =T?&a 4AF% kA� 1 D — Area <br /> —�.., <br /> Pit or Grout inspection by Date Final Inspection <br /> Additional Comments: <br /> Applicant _ Return all copies to: San J �v <br /> 1�P op Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMiT'NO. <br /> + EH 13-2 [REV,I?x 51 <br /> EK 31.2e l <br />