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44, <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPI S 1:YEAR EROM DATE <br /> �-�- __ inplet'e 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. <br /> ,y �/� / <br /> Joh Address r t) ' �h� f` " "'6 City Lot Size/Acreage tP, <br /> BREA I�� N ��ixa�AY _Zf� <br /> J � <br /> Owner's Name /E � �L Address �• n 1 � srp Phone <br /> SP�Tk+/`l 2 32T �l17YP_T -k6—f�Z <br /> Contractor 0PLDP1ATib&1 i Address cr7 ` License No.3Jr� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service well 0 <br /> Monitoring Well <br /> PUMP INSTALLATION 9 SYSTEM REPAIR ❑ OTHER <br /> , 2.�l TO <br /> DISTANCE TO NEAREST: SEPTIC TANK _ —. SEWER LINES � DISPOSAL FLD. PROP. LINE Gi2D+ <br /> FOUNDATION /4'�O AGRICULTURE WELL OTHER WELLS PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing <br /> ['I Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing NA Specifications <br /> I'1 Public 17 Other Cl Delta Depth of Grout Seal Type of Grout —� <br /> I i Irrigation —Approx. Depth I I Eastern Surface Seal Installed by S <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms } <br /> Character of soil to a depth of 3 feet: Water table depth Q <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FILTER BEd ❑ Distance to nearest: Wel! Foundation Propeny Line <br /> f SEEPAGE PITS 11 Depth Size Number <br /> l SUMPS LI Distance to nearest: Well___�� Foundation Property Line <br />! DISPOSAL PONDS . 0 <br /> t 1 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 /> f 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, ! 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."JlS� <br /> The applicannt 7st all f it re ire' cuons, Complete drawing on reverse ems. /� <br /> Signed X._ <br /> Title: - � _ Date: �� 7 <br /> F EP NT USE ONLY <br /> Y3 3. <br /> Application Accepted'by bate Area 9 <br /> Pit or Grout Inspection by Date Final Inspection by Date -17 C <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E, Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK 8 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EM13-24IREV.i/HS) 3yl7 y-S-�/ GI <br /> EH 14-2E 11 <br /> 1 � <br />