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i <br /> i <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 /> PERMIT EXPIRES 1 YEAR FROM DATE 1. JI <br /> (Complete in Triplicate) <br /> sr <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 f <br /> Joaquin County! .Q Public Health Services. <br /> Job Addressty ]'� ; <br /> TZ � urn._ R1/ Lot Size/Acreage �� S <br /> CitY'• c�/ <br /> 7 <br /> Owner's Name G tCkk "A X> - Address �n/j"�t ; -- Phone �/ <br /> \* e � /' �.S` %O/� I7 Licsense N ��' Phone <br /> `�Conlraclor/\G ( .,Address. <br /> TYPE OF WELL/PUMP: WELL WELL REPLACEMENT ❑ __ —DESTRUCTION.D Out of Service Well ❑ <br /> PUMP INSTALLATION;K SYSTEM REPAIR ❑ OTHER ❑ Monitorin�.Welh ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD.' PROP. LINE 10 1 <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE t, LTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial pen Bottom © Manteca Dia. of Well Excavation ir Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack E Tracy Type of Casings Specifications <br /> I'I Public I_.1 Oih n Delta Depth of Grout Seal 42M / Type of Grout <br /> t>dr <br /> tioation _,Approx. Depth U Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump .J H.P. 3 t7 -_ _ State Work Done <br /> Well Destruction ❑ Well Diameter% _ Sealing Material & Depth t <br /> Depth �`� �t Filler Material & Depth N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION [ I DESTRUCTION I I (No'septic system permitted if public sewer is <br /> t <br /> available within 200 feet.) <br /> Installation will serve:^-Residence— Commercial'_ rOt4er � <br /> Number of living units: """Number of bedrooms <br /> Character of soil to a depth of 3 feet: r i Water table depth <br /> SEPTIC TANK. ❑ TypelMfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ I� #: Method of Disposal <br /> Distance to nearest: Well FoundationProperty Line <br /> LEACHING LINE ❑ No. & Length of lines TotaIAe-ngth./size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation +'Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS f l Distance to nearest: Well Foundation f Property Line l /1 <br /> DISPOSAL PONDS El <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 sddh manner as to become subject to workman's compensation laws of California.'`.Contractor's hiring or sub-contracting signature <br /> certifies tFie 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 req d inspections. Complete drawing on reverse side. ; <br /> Signed X Title: it1h-- Date: <br /> EPARTMENT USE ONLYfrD <br /> Ci <br /> Application Accepted by DateF Area <br /> t <br /> Pit or Grout Inspection by Date 0 <br /> Final Inspection by fir- �� / Date <br /> Additional Comments: J" f�� / �✓ J <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 95201FEE ��\' <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH K I RECEIVED BY DATE M�2014+22_ <br /> + EM EH 3124IREV.rin51 l { Q� �� �-/ r" (� "VJ <br />'i 1 '(0) <br /> _ P <br />