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II <br /> �* APPLICATION FOR PERMIT <br /> jl <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> it 1601 E. RAZELTON AVE. , PHONE (209)468-3420 � <br /> it P 0 BOR 2009, STOCKTON, CA 95201 I <br /> lntru�rT E%PIRES 1 YEAR FROM DATE QED <br /> (Complete in Triplicate) <br /> i <br /> I� Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> i application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sen <br /> Joaquin County Public Health Services. � 1 <br /> City a / r✓ Lot Size/Acreage <br /> Job Addresry� <br /> `8Le SS�H ICeti r NtS 5 /,` _ Phpne <br /> Owner's Name Address 71/ <br /> Contractor f1N� r <br /> " U Address A) �� dt-1 License No. . tl Phone <br /> of Service Well D <br /> TYPE OF WELL/PUMP. NEW WELL I WELL REPLACEMENT DESTRUCTION i7 Out <br /> PUMP INSTALLATION SYSTEM REPAIR D <br /> OTHER O Monitoring Well C7 <br /> SEWER LINES <br /> DISPOSAL FLD. PROP. LI NE�_�f11�{ <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> i FOUNDATION AGRICULTURE WELL' _ OTHER WELL'�S� - <br /> il <br /> 4r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION d �L <br /> II= n 1 strias *• 00pen Bottom - D Manteca Dia. of Well Excavation 9-- Dia. of Well Casing <br /> Type of Casing Specifications-. gdA - <br /> DomesticlPrivate ❑ Gravel Pack C1 Tracy yp Type of Grout_ <br /> -1 Other #l Delta Depth of Grout Seal <br /> I.1 Public } <br /> I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> IU T ,�G4 R H.P. State Work Done <br /> 1 Repair Work Done Type of Pump b., Sealing`Materisl & Depth <br /> Well Destruction D Well Diameter r W <br /> Depth Filler Material & Depth <br /> 13 <br /> f1 �: TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I INo septic system permitted if public sewer is <br /> l available within 200 feet.) <br /> Installation will serve; Residence— Commercial_ Other t <br /> II Number of living units: Number of bedrooms <br /> f{ ii Water table depth Character of soil to a depth of 3 feet: <br /> SEPTIC TANK D Type/Mfg Capacity : No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t <br /> LEACHING LINE Ll' No`& Length of.Iin4lk. Total length/size <br /> FILTER BED CI Distance to nea4` Well Foundation Property line <br /> 3 w <br /> II <br /> !SEEPAGE PITS 11 Depth-* '"'`"-"� Sizey Number <br /> .SUMPS r CI Distance to nearest--,,-WellFoundation Property Line <br /> n DISPOSAL PONDS � C7 � ) <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 s _J ---> , <br /> y <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 /> I i 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." <br /> II The applicant must for all required 'nspec 'ons. Complete drawing on rev;rsosid�e. _ <br /> II <br /> !signed X -Title: Date: <br /> )' ,.� A F DEPARTMENT.'USE ONLY <br /> i Application Accepted by �' Date Area <br /> Pit or Grout Inspection by Date ` Final Inspection by Date <br /> II �Additional Comments: U Y J <br /> VIpp11nt - Return all copies to: San Joaquin County Public Health <br /> ? Services, Environmental Health Permit/Services <br /> Se 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 <br /> liIFEE NFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED By DATE PERM17'N0. to <br /> +:EH13-24Mev,1/851 <br /> II EH;4.20 <br /> i <br />