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APPLICATION .FOR PERMIT .lr•�c��s�r��� <br /> SAN JOAQUIN COUNTY PQBIYC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E: HAZPLTON AVE: j PHONE (209)468-3420 <br /> P O BOR 20091 STOCKTONi, CA 9520i <br /> PERI[IT. EXPIRES i YEAR VAQl4_ ANTE ISSUED <br /> (Complete in Triplicate) <br /> Applicdtioti i6 h6t4oi* made to San Joaquin County for a permit to coh6t-Uct snd/o'r instAil the work herein described. This <br /> application is made in co4liance "with San Joagtiin County Ordinariep No. 549 and 1862 ilhd the Rules and Regulations of San y <br /> Joaquin County Publ <br /> ic HeAlth Servicedi <br /> Job Address �e+,2_ r� d e L'71 e. YIrIi�l Yom_ City Lot Size/Acreage _ <br /> /� 3 <br /> Owner's Name Q-0 f4 4fy 6 Address "6�. - - - - --- -- Phone <br /> .,I <br /> Contractor bs Addidss' License No. Phone �I <br /> TYPE OF WELL/PUMP;P; VJNEW WELL aL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSfALLATLON � SVSTtM 4PAIR © &HER 0 . Udnitoru Well U `I <br /> DISTANCE TO NEAREST. SEPTIC TANK -t ell)- SEWER LINES <br /> DISPOSAL FLR. PROP. LINE i 3 ' <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WILL PROBLEM AREA C6NSTRt1CTION SPECIFICATIONS <br /> fl Industrial Open Bottom ❑ Manteca Dib. of Well Excavation Dia. of Well Cdsino Domestic/Private - ❑ Gravel Pack ❑ Tracy Type of Casing.. .. ,� /Ic- <br /> specifications , <br /> I'I Public (:1 Other Delia Depth of Grout Seal .�C��/ Type of Grout <br /> i <br /> i I Irrigation 3/Approx. Depth i I Eb§tern Surface Saal Installed by N , <br /> Repair Work Dane 0'. Type of Pump H.O. Statb Wdrk Dane — z' <br /> Well Destruction dWell Diameter Sealing Ftaterial & Depth <br /> pepih Filler Math` Ai i Dbpth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ 1 REPAIR/ADDITION t I DESTRUCTION I I INd septic system permitted if public "sewer is S-^• �I <br /> F available within 200 feet.) �I <br /> Installation will serve: : Residence^ Commercial Others <br /> Number of living uni i; Number of bbdrooms _ _ — A�`� <br /> Character of$oil to a depth.of 3 feet: (Nater table depth !� <br /> x <br /> SEPTIC TANK. ❑ TypellUlfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Dispasak <br /> Distanc6 to nearest: Well Foundation Property Line ,. <br /> I <br /> LEACHING LiNE C1 No. & Length of linria <br /> FILTER BED L"1 Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS I I Depth SiiA No}nb r <br /> SUMPS LI Distance to neire§t; . Well F6r}hdation Property Line t, <br /> DISPOSAL PONDS <br /> I hereby certify that i have prepared ibis 6pplicatldh and that the work will tie donb In iccordanc9 with San Joaouin county ordinances, state laws, and <br /> rules and requidtion3 of the San Joaquin County <br /> Home owner or licensod agent's signature ceriifidi the following: "I t6dify that in the performance of.'Ihe work for which this permit is Issued, I shell not <br /> employ tiny person Ih such manner as to becomb iijbjeci to workman'$Compensation iAwa of Celiforiii6 "Contractors hiring or sub-cohiracting signature <br /> certifies the fallowing:"I Cattily that in the pertcirrnanca of the work for which this permit is issued, I si'iall employ peraaiis subject to Workman's Campansa- <br /> tion MM of California." i <br /> The applicant must call fol alj "required tnspectionii. Complete drawing tin reverse aids): <br /> Signed X Title- ....Date: . ' <br /> «r _ <br /> i e---yF0 EPOTMtNt U9E ONLY 1 r� i <br /> �`~ ! <br /> Application Aet aptad by Data Q, Area <br /> f; <br /> Pit or Groin Lnipeciion by ate Finel I660ection by �� _ Dates <br /> Additional Commenis: <br /> Applicant - Retuirn sil eopieri to, San Joaquin County Public Hedlth <br /> Service6, Environmental Aegith Pe'r`mit/Service§ <br /> 1601 E, Hatelton Ave., p 0 Boz 200gi Stockton, to •95201 x <br /> INFO FEE AMOUNT I]elE AMOUNT ltEMiTT£D CASH RECEIVED BY BATE PERMIT•NO. <br /> + EHi3-24IREV.rinii) QA <br /> EH 14.20 <br />