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s <br /> rs APPLICATION FOR PERMIT <br /> -1�1 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 /> PERMIT 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 1862 and the Rules and Regulations of San <br /> (�/ Joaquin County Public Health Services. <br /> 'J� Job Address /4- 770.-+-s� �y-47�� City I C Lot Size/Acreage 1pi 0 flG c <br /> \\Owner's Name iysyo-d rIleAddress /.:�,44 .� ItS If Phone 4 <br /> X Contractor ?nd_ Set Address w r%o+eC i ense No. Y73 Y1! Phone 4-IL-MY-7 <br /> TYPE OF WELL/PUMP: NEW WELL O LL REPLAItrENT O DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEREPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUR LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom ❑ Manteca ta. Well Excavation Dia. of Well Casing <br /> [I Domestic/Private O Gravel Pack ❑ Tracy t`Type o Casing Specifications <br /> f'] Public (-1 Other rl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I EasteXealing <br /> /// Surface Seal Installed by <br /> Repair Work Done v Type of Pump State Work Done <br /> Well Destruction O Well Diameter Material & Depth <br /> Depth er Material & Depth <br /> T PE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> / available within 200 feet. <br /> Installation will serve: Residence_ Commercial_ Other tae- <br /> Number of living units: Number of bedroo s_ <br /> Character of soil to a depth of 3 feet: Sa It N Water table depth <br /> SEPTIC TANK Type/Mfg r:en eq Capacity �'�-O� No. Compartments <br /> PKG. TREATMENT PLT. Method of Disposal �} <br /> Distance to nearest: Well 2S: Foundation s, Property Line_ 2-;C <br /> LEACHING LINE f No. & Length of lines 010 Total length/sizes _ <br /> L(,ri:I,SPOSAL <br /> LTER BED O Distance to nearest: Well Foundation _. Property Line I I Depth V Size Number C?UMPS L* Distance to nearest: Well (¢©. Foundation� Property Line PONDS O <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 subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 must call for all rr uir d inspe.cAtions. Complete drawing on reverse side. / <br /> Signed X SGL / - Title: (Fig--- Date: 6 ' 9� <br /> OR Pf PARTMENT USE ONLY <br /> Application Accepted by ___cC - Date Z' Area <br /> Pit or Grout Inspection by Date Final Inspection by A Date Z� <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., 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. <br /> CASH I <br /> ddrr,, / zD <br /> . EH 13-24(REV.Iihs) r' �� ` V(9100 C�> <br /> EH 2♦-2a <br />