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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 /> ?F7PkRM1J. <br /> XPIRES 1 YEAR FROM DATE ISSEED <br /> (Complete in Triplicate) ��� lc�U0 -Z-5 <br /> Application is hereby made to San Joaqu o4ky 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> sA� 32, � <br /> Job Address N Cv,`LtJN� ! #"l Sy-1- ►t?A/L� City J"4,,J'1' Ld• Lot Size/Acreage <br /> 5'DZ ?. ­vV-4 S7-. <br /> Owner's Name AVt,61* Address Phone Z'62 -172/6 <br /> Contractor re„ O, -1 s�SSK,Address ��Z6 Lo/�/�►aaE 'Q 2-1Y License Na. Phone <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER.9 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS II <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public is Other ❑ Delta Depth of Grout Seal - ��Gam? Type of Grout SaR- e&*Te­'4 5 II <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done 15 t� 5_4 <br /> SRM�P. <br /> Well Destruction 0 Well Diameter Sealing Material & Depth 0I4 4u <br /> MovCT Depth - Filler Material & DepthSo/d— erorn <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 206 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth I <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 /> f� <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> 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 /> Home owner 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 t <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 /> f certifies the following: "1 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 /> 4 The applicant m cap for all re ed inspections. Complete drawing on reverse side. + - <br /> Signed Title: P 5i 0 � Date: Z , <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by DatFinal inspection by <br /> Date Date <br /> ` r� 4 / <br /> Additional Comments: F �14- 4lQg- r�r,1l 'tll�I <br /> Applicant - Return all copies to. San Joaquin County Pub] Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 rl{� <br /> fEEAMOUNT DUE NT T REMITTE C K RECEIVED 8Y PATE PERMIT N0. <br /> INFO q. <br /> EH13--2411tEV.i/nsis� <br /> r EH 141.20 " 412644 0� <br /> - <br />