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_. ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> CNAA ENVIRONMENTAL HEALTH DIVISION <br /> : 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PEUIT EXPIRES 1 YEAR FROM-DATE 1$$�JE <br /> (p (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. J <br /> Job Address City <— a�" t[ Lot Size/Acreage <br /> Owner's Name'-0 Co r3 u �n•C� ly�- Address , 1 IL`Z f-: Cnkf" %c Phone - <br /> ♦ � <br /> .' onlraclor .' Address </ 1�n `f�?�(�DE�__ f License No.0,y Phone <br /> TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION:R� SYSTEM REPAIR ❑ OtHER O Monitoring Well <br /> `DISTANCE TO NEAREST: SEPTIC TANK �'y r SEWER LINES DISPOSAL FLO.. � PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS { <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 IndustrialOpen Bosom Y© Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ( 'Domestic/Private Gravel Pack C] Tracy Type of CasingV Specifications <br /> I', Public , 3Z)66Other f1 Delta Depth of Grobt Sea, Type of rautS�- C':r•[rr <br /> I I Irrigation ..Approx. Depth , 11 Eastern Surface Seal Instakled by <br /> r <br /> 11r v <br /> Repair Work Done i ❑ Type of Pump �� H.P. / State Work.Done <br /> Well Destruction 0 Well Diameter s Sealing Material & Depth <br /> Depth Filler Material & Depth v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is a <br /> t.. ., _ available within 200 feet,) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Character of sail to a depth of 3 feet: Water table depth <br /> F SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> p PKG. TREATMENT PLT. ❑ Method of Disposal � ) <br /> i Distance foto n _ Well Foundation{ Property Line (Npv <br /> t e s <br /> 4 LEACHING LINE ❑ No. & Length of lines,I Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line ! <br /> SEEPAGE PITS It Depth " Size Number J <br />' SUMPS Ll Distance to"nearest: Well Foundation Property Line <br /> ,r DISPOSAL PONDS ❑ <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 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." G <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X ,/ N /11/ Title: :- fin T _ Dat <br /> f <br /> TMENT USE ONLY <br /> ' Application Accepted by 4kAk NN15 --lit,9 Date __ ~ ! Area <br /> Pito Gro,t Inspection by 11 �at�6- Final Inspection by Date, 22 " <br /> k Additional Comments: DA&P <br /> A Uh&A • <br /> .. 1 <br /> Applicant r,Return-all.copies-to:"- San-Joaquin-County Pub1"ic"health- : N 'f <br /> Services, Environmental Health Permit/Services y <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 1 <br /> FEE AMOUNT DUE- OUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH <br /> EH 13-24 tREv.IIK51 / ' <br /> �H 9I-2a I � ♦ / O' <br />