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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> gEMIT XMIRES 1--YEAR ?ROM—DATE ISSUED <br /> 4 (Complete in Triplicate) <br /> Application is hereby made,to Scut 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 1662 and the Rules and Regulations of San <br /> i Joaquin County Public Health Services. <br /> 1` Job Address _ ZOX!Z ; Al, EA l='D City 4-/A1A,!F_AtJ Lot Size/Acreage <br /> Owner's Name Address J W AhVIZ77 �yA.� I>k-.—?1�g� Phons ` r -f <br /> ' AA �reTAr/ License No. �� Phone " <br /> Contractor��� ��� Address 7 JZ< <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C_l ­�DESTRUC-TION--CI-Out of Service bell <br /> i PUMP INSTALLATION 0 . SYSTE EPAIR 0 OTHER ❑ Monitoring Well <br /> I DISTANCE TO NEAREST:: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �o} <br /> r FOUNDATION A RICULTU WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE `� TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> U Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> M Public ('1 Other 0 D a pth of Grout Seal Type of Grout <br /> CJ Irrigation �. Appro>t_ Depth_� , astern Su ace Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done ._ <br /> Well Destruction ❑ Welt Diameter Sealing MaterlAi & Depth <br /> t Depth i Filler Material A Depth <br /> TYPE OF SEPTIC WORK:..,.NEW INSTALLATIONA REPAIRIADDITION 0 DESTRUCTION CI.fNo septic system permitted if-public sewer is. <br /> 4, I available within 200 feet.) <br /> Installation,will serve: Rasidence'_e Residence'! Commercial_ Other <br /> Number of living units: / Nurriber of bedrooms 11 <br /> Character of &oil to a depth.cif 3 fist: 6',4 Al C 1-A V Water table depth <br /> SEPTIC TANK TYP*/-Mfg C ��'G CapacityJ`Zf,1D - No. Compartments 2= r <br /> PKG. TREATMENT PLT. C1 Method of Disposal <br /> Distance to nearest: WellaL O._ FoundationProperty Line /04i1 <br /> LEACHING LINE Ir Na. 8 Length of lines '` ( Total length/size f " <br /> FILTER BED r. -171 Distance to:nearest: Well . IPS?'` Foundation Property Line <br /> SEEPAGE PITS Depth Z-:c - = Size �r Number_ .1 <br /> k SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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-becorne'subject to workman's-compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the perforr'nance 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 call for sit required inspections, Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEP fiTMENT USE ONLY <br /> Application Accepted by Dare as <br /> C Area <br /> Pit or Grout Inspection by Date Final Inspection by Date r <br /> Additional Comments: — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 495 N SAN JOAQUIN, P O BOX 2009, STOCXTOH, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMfTTED CK CASH RECEIVED BY DATA PERMIT NO, <br /> a <br /> EH 13.24 IREV. <br /> 166/3 ' �� r 1 4V , <br /> EH 12fi <br />