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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)465-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PER,d12 EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby [nada to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> r 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 /> Job Address �.J� 4,07 Sr City1-'4JetX1A1C-7V/ULot Size/Acreage <br /> Owner's Name -AA 93ek 41 VPhone Address � � gp`�- <br /> S �a <br /> _ <br /> Contractor L.t� �+�r-----aAddress LLQ- '-T License No. 7►-7 PhoneS�-. 9 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ <br /> { PUMP,INSTALLATION .0 �� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK �,SEWER-LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE-WELL' r" OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' i Dia. of Well Casing # <br /> P C7 Public Domestic/Private Cl Gravel Pack [].Tracy `� Typeof Casing ' Specifications-- <br /> [-I <br /> pecifications {'1 <br /> i'1 Public [-I Other w' I-1 Delta°/ Depth of Grout Seal �l <br /> r r Type of Grout <br /> I I Irrigation __.Approx. Depth l I Eastern Surface Seal Installed by `• <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> f Well Destruction 0 Welt Diameter 1 =j Sealing Material & Depth 't. <br /> Depth Filler Material 5 Depth t e <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION, I (No septic system permitted if public sewer is <br /> / available within 200 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 <br /> SEPTIC TANK. ❑ Type/Mfg JQ=Ng G_apacity h-a-_0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ yl Method of Disposal VJ <br /> Distance to nearest: Well Foundation Property Line /P` <br /> LEACHING LINE No. & Lertgth of lines Toral length/size <br /> FILTER BED ❑ Distance to nearest:-'"1 Well, Foundation _ .6c7 F -_ Property Line �1 <br /> SEEPAGE PITS I Depth f Size �f Number <br /> SUMPS LI Distance to nearest: Well_ o Foundation die ` 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 cenifiei 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 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." 4 <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: Ao--4&---'02 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date -AV—/y <br /> ;Z_Ar a Zif <br /> Pit r Grout fns ction b l <br /> pe y Date Final Inspection by _ Data <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.. F 0Box_2009, Stockton, CA 95201 <br /> t FEE AMOUNT DIE uAMOUNT REMITTED H RE BYt'1 PERMIT'NO. <br /> INFO EIVED�s <br /> « EH i3-24{F3EV.t i H SI w / DATE <br /> EH`s426 <br />