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# APPLICATION FOR PERMIT <br /> �] r <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH <br /> Aid SON VICES <br /> ENVIRONMENTAL HEALTH <br /> 1601 P-O BOX 2009, STOCKTONZELTON AVE. , I, CA095201-5 20 ' <br /> f <br /> EgpiRES 1 YEAR FROM DAT�9AW <br /> (Complete in Triplicate) <br /> e to San Joaquin Gounty for a permit to construct and/or install the work herein described. Tan <br /> Application`is hereby mad . <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of an � <br /> Joaquin County Public Health gervicea.�� city S►r5(_1Z "` Lot Size/Acreage <br /> O 6 <br /> Job Address A `w 3 r- Y312 - <br /> aW � Address <br /> !�L Phone F <br /> Owner's Name <br /> v15 License No. �3 .r Pt1on 3�� <br /> eL Address put of Service We11 ❑ <br /> Contractor WEL�AEPLA CEMENT -. DESTRUCTION <br /> NEW WELL OTHER ❑ Monitoring Well ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ § <br /> PUMP INSTALLATION/ «„_ DISPOSAL FLD. PROP. LINE - w <br /> DISTANCE TD NEAREST: SEPTIC TANK JL -- SEWER LINES PITS/SUMPS <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL -� , <br /> t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> " <br /> INTENDED USE 1 •�J Dia. of Well Excavation r Dia. of Well Casing Y " <br /> ❑ Open Bottom ❑ MantecayG Specifications - r <br /> E� Industrial _ ' Type-.af,Casing / <br /> C7 Tracy - j�.�. - Type of Grout_ t�IJ�cN� <br /> Domestic/Private t-C1 Gravel-Pack-° �Jn Delta Depth at Grout Seal <br /> 1'1 Public {# I] Other CrX-T <br /> Approx. Depth I I Eastern Surface Seal installed by <br /> i 1 1ni0ation I Z State Work Done .,. <br /> $'4410 H.P. <br /> Repair Work Done ❑ E Type of Pump �--- Sealing Material & Depth <br /> Well Destruction ❑ 4 Well Diameter Filler Material & Depth 1 <br /> I Depth <br /> available within 200 feet.) <br /> TYPE Of SEPTIC WORK: NEW INSTALL p,TION I I REPAIR/ADDITION l I DESTRUCTION 1 I iNo septic system permitted it public sewer is <br /> Installation will serve: Residence Commercial— Other� — <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: �~ <br /> Capacity..��-.—� No. Compartments <br /> SEPTIC TANK I Cl Type IMfg ' Method of Disposal <br /> PKG. TREATMENT PLT:❑ <br /> i. Foundation Property Line <br /> Distance to nearest: Well <br /> +.t Total length/size <br /> LEACHING LINE Cl No. & Length of linesM�..— Foundation Property Line <br /> - <br /> FILTER SED Cl Distance to nearest{'-" Well. <br /> t � <br /> i Number <br /> f <br /> SEEPAGE PITS s ill 1 Depth t Sue Foundation Property Line <br /> SUMPS Ll Distance to nearest{ I Well <br /> t ! ,1.,. � <br /> DISPOSAL PONDS D ` <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 <br /> rules and regulatibns of the San Joaquin County f <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, l she not <br /> ecome subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature <br /> emplpy any person 3n such manner as to b <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 c 11 for Il�quired inspections. Complete drawing on reverse side. �,�s�q <br /> Signed <br /> �/— Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> Date �- 1 --9.1 Area <br /> App11t Accapted by dao •� Z <br /> j '� Date <br /> DataT Final Inspection by <br /> Pit Grout nepection by / <br /> Additional Comments: G Qom_ j 1 <br /> Applicant - Return ail copies to: San Joaquin County Public He <br /> Services, Environmental He th Permit/Services <br /> �+ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE ' AMOUNT DUE AMOUNT REMITTED CASH �1 ice- GSI 11 <br /> INFO ' y <br /> . EH 13-24 1REY.I/a 51 0 0 1� t v `134PO C� <br /> EH 14.26 l - <br />