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I I <br /> APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 'M ENVIRONMENTAL HEALTH DIVISION10 <br /> C 160 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> yt L� x P O BOX 2009 STOCKTON CA 95201 AF Z '• <br /> ' QfW c <br /> PERI[IT (Complete inATriipllidcate} ISSUED pelw � <br /> I! h lr�- <br /> Application is hereby made•to San Joaquin County for a permit to construct and/or install the work herein de'scrLibed.�j This <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regul6tione of San <br /> Jc'iquin County Public Health Services. .J <br /> Job Address L � �� ��£ City Lot Size/Acreage <br /> owner's Name �,� !/ SFL� Address —X- S S ry .0S� Phone C-qO. <br /> -B � _ �-__ <br /> I <br /> ConEraclor �6�F Address License No. Phone li�c <br /> TYPE OF WELLIPUMP: NEW WELL ❑ W LL REPLACEMENT ❑ DESTRUCTION ❑ Out of Sell <br /> rvice We ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Moni ioring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS, <br /> ^­9fINTENDED,USE—7�=—TYPE-0F-WELL­' -PR0 LEM AREA CONSTRUCTION SPECIFICATIONS <br /> L�;Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> b(�Domestic/Private Gravel Pack Tracy Type of Casing %VC� Specifications r <br /> I'!4Public i 1 Other hI Delta Depth of Grout Seal Type of Grout <br /> I I ftrigation _Approx. Depth I 1 Eastern Surface Seal Installed by �M <br /> Rep ai►Work Done 0 Type of Pump <br /> p � 2 H.P. - State Work Done <br /> W _ <br /> u' Sealing Material & Depth !� <br /> ell Destruction ❑ Well Diameter � <br /> I� Depth Filler Material & Depth <br /> • I � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION id INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other (� <br /> k <br /> Number of living units: Number of bedrooms �. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal11 I� <br /> I <br /> Distance to nearest: Well Foundation Property Line <br /> ry. <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> I <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ,_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 /> rulas 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, 1 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." <br /> T applicant st c I fa requi inspections. Complete drawing on reverse side. <br /> Signed X Title: O W eJ 64 Date: <br /> =ORPARTfNENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit ll or Grout Inspection by Date Final Inspection by Date <br /> !p' I <br /> Additional Comments: <br /> Applicant - Return a copies tor Mn uotin"ty`Putilic nealth�' <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box.2009, Stockton, CA 95201 = <br /> INFO 01 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE oPERMITi NO. <br /> rcM13-21[REV,f�Ntl 3S. �"U _3S oZ7 p27ZQ If CO Gd �7 <br /> {H 7b26 <br />