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APPLICATION FOR PERMIT <br /> T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ,PFAMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 i <br /> Joaquin County Public Health Services. <br /> Job Address _ 7421 u Y e a-- City Lot Size/Acreage /a /3t 3,910 <br /> Owner's Name ! ►� '� �� 5t! " Address + �-, Phone <br /> 4-1Contractor ��lJ� Address t � 0 A' � Iv+ - License ND /2f'_�hone / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out.of Service Well ❑ <br /> PUMP INSTALLATION ❑�''� SYSTEM REPAIR ❑ OTHEVC Monitoring Well C7: <br /> DISTANCE TO NEAREST;: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP..LINE i <br /> FOUNDATION AGRICULTURE WELL �. 4THER•WELL PITS/SUMPS _' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATJONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing � ' `*''Specifications w <br /> Il Public l : L7 Other fl Delta Depth of Grout Seal Type of Grout <br /> 11 1rni0a,Iion —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work`Done 0 Type of PumpH.P. State-Work Done--. <br /> Well Destruction ❑ Wail Diameter A r ,` Sealing'Material-&,•Depth <br /> Depth Filler Material & Deptht. - e <br /> S <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION/ REPAIRlADDITION I 1 DESTRUCTION I I (No septic-system-permitted ihpllblic-s6w`er"is�-1�`= <br /> // available within 200 feet.) �` <br /> Installation wilt serve: Residence_ Commercial_f�'iOther p' 7`feCt1 ® r <br /> Number of living units!_,, A }Number-of bed,'..,;.- j'T� <br /> Character of soil to a depth of 3 feet: r r t Water table depth <br /> SEPTIC TANK. reg Type/Mfg w ti Capacity. '�.L� No. Compartments <br /> PKG. TREATMENT PLT, lyl _ '• Meth4of.Disposal - <br /> Distance to,nearest: Well���(Qt� Foundation Propine <br /> LEACHING LINE Nor & Length of lines } t , Jcital.length/size> <br /> fIL/TERaED= FJ�btstsnce to nearest: Welles Foundation It�,�' Property Line ]S� T <br /> LX <br /> SEEPAGE PITS 4e/Depth S _ _Size ��-:�.3 . rR, ' "Number (� <br /> SUMPS Ll Distance to nearest: Well y Foundation t Property 6ne -J <br /> DISPOSAL PONDS ❑ �, 3 <br /> I hereby certify that I have prepared this,application and that the work will be done in accordance w`11h=San.Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Codnty, <br /> Home owner or licensed agent's sigriature 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 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." t ,l I <br /> The applicant m t J for all�red inspect; . Complete drawing on reverse side.bSignTitle: <br /> t r <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by _ Data r r' rO Area <br /> \-r <br /> Pit or Grout Inspection by - ° -z_ Date Final Inspection by 5 <( Date 3U , <br /> JO . Additional Comments: <br /> ApplicamtJ -;,Return.all'copies to: San Joaquin County Public Health <br /> F'. 1' •"� vj Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PPyERMIT'/NS,O. <br /> CH 13.24 IFIEV.i im sr - G{J, si✓ v , - 7!1 <br /> E H 11.2E 0 <br /> i 1 -i <br />