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77 ,:" <br /> APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> \,� 1 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> j� P O BOX 2009, STOCKTON, CA 95201 <br /> PERI[IT EXPIRES I YEAR FROM-DATE- IS-SN? <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 j <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 /> Job Address r City Lot Size/Acreage <br /> Owner's Nameti �L' ��9?K0<%(:ZA - Address Phone <br /> Contractor Address License No.h7. cSr _Phone _q <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACE�MF�JI. C DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L] OTHER © y Monitoring Well C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSI� <br /> INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom ❑ Manteca Dia- of Well Excavation lDia..of;Weil "sing g <br /> f_7 <br /> Domestic/Private ❑ Gravel Pack ,' ❑ Tracy Type of Casing '. Specifications <br /> f'1 Public [:1 Other E n Delta Depth-oF:Graut-$eal �' Type of Grout <br /> I I Irrigation ! Approx. Depth I I Eastern Surface Seal In tafl'ed,by <br /> Repair Work Done U Type of Pump r H.P. Ste 'Wolk Done� i �� a•' <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth r ` <br />` Depth Filler Materiel & Depth ry` ' -•__ ` -`; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'I ,1 REPAIR IADDITIONDESTRUCTION I;I.(No septic system permitted if public sewer is <br /> t '`*' available within200 feet.) <br /> x <br /> Installation will serve: Residence—k-"Commercirii Other k a� <br />' Number of living units: _� Number of bedrooms- ? ' <br />} Character of soil to a depth of 3 feet �d-b -___ -_ __ - _ - - __ Water table depth <br />' SEPTIC TANK ❑ Type/Mfg L a = aF' <br /> =Ca crty - No. Com artments <br /> M <br /> PKG. TREATMENT PLT. ❑ ""•- ; Method of Disposal �r <br /> F - i <br /> Distance to nearest: Welf — Foundation` �``Rroperty Line I <br /> LEACHING LINE U( No. & Length of lines Total lringth/size r771 <br /> FILTER BED Cl . Distance to nearest: Weil yj, Foundation -r Property LineFT <br /> SEEPAGE PITS 11 Depth Size Nilmber <br /> Ik <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line I �� <br /> DISPOSAL PONDS ❑ ,` -3„ ^� - `' <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 o►sub-contracting signature <br />'s'• 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." '.� `. i <br /> The applicant must call for all required insPections, Complete drawing on reverse side.. . ,_ 6 I <br /> I -4 , { � - <br /> Signed X 62-Title: ` Date:a^fl <br /> RDEPARTMENT USE ONLY, <br /> Application Accepted by .01t< <br /> Data C Area ! <br /> Pit or Grout Inspection by Date '' ` �. Final Inspection by I 1Dilater L3 <br /> �.. / <br /> f-y r <br /> Additional Comments: • <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services I <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ,CK RECEIVED BY-.? DATE , _.PERMI7"NO..-- - <br /> �.. �..,. ,.. _. _ INFO - -- -CASH-..'�-:., - - � _...• •.. <br /> v. 1A0A <br /> EH 13-24(REV.tRti <br /> EH 11.25 <br /> _ x11 <br />