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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$-3420 <br /> P O BOX 2009, STOCKTON, CA95201 <br /> PERMIT EXPIRES 1_YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby nude,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 Pub He lth Services. <br /> 6 9b/�1� v d <br /> Job A�dress CityLot Size/Acreage <br /> I OwnesName S&&1A,Address --_—_ Phone <br /> 44 <br /> Contractor-J���-�- - S*' Address i License No?_ZZL Phone <br /> TYPE!PF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Out of Service well ❑ <br /> I I`' PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> Ip. FOUNDATION AGRICULTURE WELL- OTHER WELL PITS/SUMPS ` <br /> INYENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n lndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav&Oon Dia. of Well Casing. <br /> Olestic/Private Gravel Pack C1 Tracy Type of Casing 0<1 Specifications /� <br /> i'l Public Cr-l Other n Delta Depth of Grout Seal OaType of Grouts" ~11W - <br /> I Irrigation —.Approx, Depth l I Easternurface Seal Installed by <br /> Repair Work Done U Type of Pump 6 H.P. <br /> Ad State Work Done .mss <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br />` sir DepthFiller Material & Depth <br /> TYPE:10F SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I l INo septic system permitted if public sewer is <br /> k I -available within 200 feet.! <br /> Installation will serve:' Residence_ Commercial— Other <br /> Number of living units: Number of-bedrooms <br /> rCharacter of soil'to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0 ;:, Method of Disposal � + <br /> Distance to nearest; Well FaundationProperty Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br />� I <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS LI Distance to nearesu. Well Foundation Property Line <br /> 4 DISPOSAL 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 /> rules and regulations of the San Joaquin County <br /> Homeiowner or licensed agent's signature certifies 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 cyauired <br /> ten the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor Ia." <br /> i <br /> The applicant t call foinspections. Complete drawing 2L_ <br /> side. <br /> I <br /> Signed X Title: M'a$ _ Date: AV'���- <br /> FO DEPARTMENT USE ONLY lf <br /> Application Accepted by " Date ��-l� Z--" Area 2 L <br /> Pit orto <br /> Inspection by Date , Final Inspection by Data <br /> Additional Comments: <br /> ih <br /> t Applicant - Return all copies to: San Joaquin County Publ c Health <br /> t Services, Environmental Health Permit/Services <br /> l 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEErIIN�F�Oy AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> . EH 19,21 IREV. <br /> EH 1.4.26 11 <br /> �, f.v �a <br />