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APPLICATION FOR PERMIT fi <br /> AAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES e3! ti�S3W���n� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-342dCln µ i <br /> p o BOX 2009, STOCKTON, CA 95201 r3 <br /> pERMIT .EXPIRES 1 YEAR FROM DATE LE§gEWD <br /> (Complete in Tripli-Cate) <br /> Ttuis <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install thew a one of San <br /> application is made in eonpliance with Elan Joaquin County Ordinance No. 549 and 1862 and the Ru l 1 <br /> Joaquin County Public Health Services. 1 1 <br /> 141 North E1 Dorado City Stockton Lot Size/Acreage ! <br /> Job Address CA 95818 9 <br /> CM Weber Enterprises/ <br /> 1 561 <br /> Owner's Name <br /> Gertrlade Weber _ Address X3757 College Ave. . Sacramento Phone �1F1 - <br /> t <br /> PC Exploration Address 1780 Vernon St: W License No. 265 556 Phone 9 - <br /> 973 <br /> Contractor 3 <br /> DESTRUCTION C] Out <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll tAonitoring Well C] j <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER f� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRf7P"tlidf soil been <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIl`S/ tlisRf'S t�30 feet <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> (� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6-inch Dia. of Well Casing Nnrtp— <br /> C_I Domestic)Private ❑ Gravel Pack ❑ Tracy Type of Casing None Specifications <br /> I'! Public 1-7 Other Cl Delta Depth of Grout Sealf 'Type of Grout <br /> I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by. <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> D th <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & ep <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No s ptic thin stem <br /> m retitled it public sewer isavaila \ <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 <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 1 <br /> Distance to nearest: Well foundation Property Line <br /> -LEACHING LINE ❑ No. 1k Length of lines Total length/size a <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> v b <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS El 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 <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 canify 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 ;all f&Adl r uired inspections. Complete drawing o1n�reverse <br /> lside. �l ,1 <br /> Signed X /fir [/ Ch`s - - Title: tr f-a� rJ/Ll!�1� �1�u Date: �I Z I(p <br /> O <br /> =7"SE ONLY <br /> Application Accepted by Date Area !� <br /> Pit or Grout Inspection by Date Final Inspection <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> / 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I ASR RECEIVED BY DATE PERMITNO. <br /> INFO <br /> EH 13-24.11PIEV <br />