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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 PAW-�',`,'T <br /> P 0 BOX 2009, STOCKTON, CA 95201 REC . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 17 <br /> (Complete in Triplicate) SAN JOAQUIN C. i'Y <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or instaB ct? �edl This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 an� l81whb%ftan <br /> Joaquin County Public Health Services. <br /> Job Address ���oo ' A;?,0 �- y'n/0 i City ! r/�,� <br /> AA71_ec,4 Lot Size/Acreage 1743 <br /> O er's <br /> KI.— a 4ems1-ON& Address .51q" e"" Phone <br /> a�2 ^� f� <br /> Contractor ��/°� " "-� Address J00 fox 9a7'M '10�cense NON �1J Phoneva3 3613 <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ <br /> UMP IN ALLATIO SYSTEM REPAIR ❑ O�TtHERR ❑ Monitoring Well [3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _G>rcS' . DISPOSAL. FLD.I�.L PROP. LINE � S <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAJ�ONS <br /> n Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ( <br /> JK Domestic/Private Of-Gravel Pack ❑ Tracy Type of Casing Specifications S 0 <br /> I'1 Public Cl Other n Delta Depth of Grout Seal / O Type of Grou <br /> I I Irrigation Approx. Dep_thIEaster Surface Seal Installed by <br /> Repair Work Done U Type of Pump �' � �H.P. 1*�-2/74_� State Work Done_ <br /> Well Destruction ❑ Well Diameter �� Sealing Material & Depth01 <br /> Depth `,r9 Filler Materiel & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Ci <br /> available within 200 feet.) (� <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms o LA <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compattments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> v <br /> LEACHING LINE Cl 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 /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> 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 /> amloy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certtlies 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 /> The applica must call for II requ ird ins pe Complete rawing/onn reverse side. <br /> Signed Title: `-'� '©4W� Date: —/,0 <br /> Z11' OR DEP RTMENT USE ONLY <br /> Application Accepted by Date Area,0;;;Z <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: A411 C �1���' <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 /> FEE AMOUNT DUE AMOUNT REMITTED Ct RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13.24 IREV.1/XSr G�o � .:q(,9 <br /> EH;1.26 <br />