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7 �7APPLICATION FOR PERMIT <br /> -,\,4.fir <br /> HEALT <br /> SAN JOAQUIN COUNTY P LITH DIVISION SERVICES <br /> ENVIRONMENTAL PRONE (209)468-8420 <br /> 1601 E. HAZELTON AVS� <br /> P O BOX 2009, gTON, CA 95201 <br /> S I YEAR FROM <br /> EX? EE D <br /> (Complete in Triplicate) I <br /> e San Joaquin County for a permit to construct and/or and i_s62 tnd theall e vorit heRules andeAegulationsin dof Sans <br /> 1lance with San Joaquin County Ordinance No. 5 9 <br /> Application is hereby mallcS <br /> application is made in camp <br /> Joaquin County Public health Services. L��j( Lot Size/Acreage <br /> City <br />` Job Address W- GL"` L_0V 1- Phone 3�a <br /> i [�� � �O t.✓ Address /3 72_/O" <br /> ilii Owner's Name u,�,q„v Phone <br /> Z License Na. <br /> A/E��- a Address v`T°� OESTRiJCTION ❑ put of Service Well ❑ <br /> Contractor WELL REPLACEMENT ❑ Monitoring Well 11 <br /> NEW WELL ❑ OTHER ^lvE'YT. <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR Cl 4,argiw.-IJtAPAOP. LINE <br /> I PUMP INSTALLATION ❑ DISPOSAL FLD. <br /> SEWER LINES �� PIT515UMP5 — <br /> DISTANCE TO NEAREST: SEPTIC TANK ___— At WELL OTHER WELL <br /> FOUNDATION ���--� 04v4� fk�3 <br /> TYPE OF WELL PROBL�R£A CONSTRUCTION SPECIFICATIONS AdDia. of Well Casing f <br /> INTENDED USE ❑ Open Bottom ❑ Manteca 4 Dia. of Well Excavation - Specifications <br /> I Cl industrial ❑ Tracy Type of Casing Type of Grout <br /> fl Domestic/Private ❑ Gravel Pack Depth of Grout Seal ..- <br /> F i-1 Other fl Delta rCr r4P . <br /> f ('1 public Surface Seal Installed by <br /> �.Approx. Depth I l Eastern f�� r S�'�' <br /> I i IrriOation H.P. State Work Done <br /> t -Gv 1..K <br /> Repair Work Done L7 Type of Pump _--�----- Sealing Material & Depth GuT1��L 5 �,�t• 10 <br /> � � Q <br /> Well Destruction ❑ Well Diameter — Filler Material & Dep <br /> f is <br /> Depth <br /> available within 200 feet.l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRlADDITIQN l I DESTRUCT.lON I } {No septic system permitted if public Bawer <br /> installation will serve: .Residence Commercial <br /> Other �--�— <br /> L Number of bedrooms Number of living units: eWater table depth <br /> Character of soil to a depth of 3 feet: Capacity� No. Compartments <br /> SEPT$C�TANK. ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation -- Property Line�- <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE 11 No. & Length of lines Pro ert Line <br /> FILTER BEb ❑ Distance to nearest: Well Foundation p Y <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ul Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS ❑. .T <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county or 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, l 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 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:pplicant call for all quired inspections. Complete drawing on reverse side. <br /> Signd Title: <br /> t /%rnsf l�G^�%` Date: Cd Z <br /> FOR EP MENT• USE ONLY <br /> € - Date Q 2 Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout inspection by Date Fina! Inspection by <br /> 1 f e <br /> I Additional Comments: <br /> f - ! <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 /> EFEE <br /> 114CIED BY 0 E PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED H <br /> a EH 13-24 MEV."n sr 1r <br /> / <br /> EH 14.25 _ <br />