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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROIII DAZE 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 1s 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 /> Job Address <br /> /t n City Mr-IIKMAI Lot Size/Acreage <br /> Owner's Name Aviv I3Rt�!✓S Address R0 Phone 39`7 <br /> Contractor ��� � Address <br /> TYPE OF WELL/PUMP: License No.______•____Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell O, <br /> PUMP INSTALLATION p SYSTEM REPAIR ❑ Moltor1 Nell <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PRO LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL—_ PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom ❑ Manteca Die. of Well Excavation <br /> Cl Domestic/Private O Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing_. f <br /> Il Public EI Other F1 DeltaDepth of Grout Seal Specifications <br /> Surface / <br /> I I Irrigation —Approx. Depth I I Eastern v <br /> Repair Work Done U Type of PumSeal Installed by Type of Grout <br /> Pump H.P. State Work Done_ <br /> Well DestructionO Well Diameter Sealing Material i Depth �) <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION ( I DESTRUCTION I 1 11-40 septic system permitted if public sewer is <br /> Installation will serve: Residence_ CommercialOther 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 ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT.❑ Capacity No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE O No. b Length of lines <br /> FILTER BED 0 Distance to nearest: W811 Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS 11 Depth <br /> SUMPS Size Number <br /> Ll Distance to nearest: Well <br /> DISPOSAL PONDS p Foundation Property Line <br /> 1 hereby certify that 1 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 /> Homs owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <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: permit is issued, I shall not <br /> ng: "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 Chow ng:California."" <br /> The penes• <br /> must call for all r ired inspections. Comp to drawing on reverse side. <br /> Signed �a2G �r C7 Title: lrt`hl� a <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Dots <br /> Pit or Grout In � / c <br /> Area <br /> Inspection by Date <br /> �0,� — Final Inspection by Date j <br /> Additional Comments: /•y.i;/� �s"$ <br /> lY L_ W NFCSQ- L <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 4J��fXA <br /> Environmental Health Permit/Services V� `L 1 <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE <br /> INFO <br /> AMOUNT REMITTED CK(REV.i RECEIVED BY <br /> EN 13-24 1 / 1 CASH DATE PERMIT'NO. <br />• EH 1t i h 5! L q? Z <br /> " <br />