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F <br /> R o APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE 31% <br /> ENVIRONMENTAL HEALTH -DIVISION � �� <br /> 1601 E. HAZELTON AVE. , PRONE' (209)468-3420 E C <br /> P 0 BOX 2009, STOCKTON, CA 95201 AUG 3 t M,110 <br /> PERMIT XEMMEM 1 YEAR FROM D T NI ION MI EN I A L HEALTH <br /> �7 <br /> (Complete in Triplicate) i- R i i'vE tVICES <br /> Application is hereby made to San Joaquin County 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ro "Y ..� City i lu Lot Size/Acreage <br /> Owner's Name 21 GK-! 0 LCI - Address G pon� .r��'0 t� <br /> Contractor Q w ter ! Address 61%4 License No. 391g&;. Phone <br /> TYPE OF WELL/PUMP, NEW WELL WELL Ll <br /> ❑ DESTRUCTION ❑ Out of Service well <br /> PUMP INSTALLATION C]` <br /> SYSTEM REPAIR Ll OTHER ❑ Monitorl well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.-S'V' -PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS-/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S / <br /> € ] Industrial ❑ Open Bottom -Manteca Dia. of Well Excavation n Dia. of Well Casin <br /> F7 Domestic/Private Gravel Pack 11 Tracy Type of Casing . <br /> Specifications <br /> I"I Public 1-1 Other ❑ Delta Depth o! Grout Seal Type of Grout <br /> I 1 Irrigation -..._Approx. Depth I I Eastern Surface Seal Installed by 0 <br /> Repair Work Done 0 Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALI1ATION I-1 REPAIR/ADDITION I I .DESTRUCTION I IANo septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial— Other available within 200 feet.► <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br />` SEPTIC TANK. Water table depth <br /> D Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. D <br /> Method of Disposal i <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> — Number <br /> SUMPS <br /> LI Distance to nearest: Well -Foundation <br />= -.-DISPOSAL PONDS p _ Property Line L <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 subjedt 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m c or al requ spe.ctions. Complete drawing on re se side. <br /> Signed <br /> Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date �j <br /> Area <br /> Pit or Grout Inspec ' n y Pate I <br /> /� Fi al Inspection by-. Date ` c9 Q� <br /> Additional Comme� �L /fir <br /> Applicant - Return all c 1 <br /> opies to: San Joaquin County Public Health <br /> t[*( <br /> Services, Environmental Ave.. Health Pe t/Services � fNSo. C- <br /> EH <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 952 1 pl!FEE AMOUNT DUE AMOUNT REMITTED CKINFO CASH RECEIVEp i3Y DATE PERMi ��13-24(REV.t i x Sl <br /> EH Z4•2a <br />