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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> t . PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sea Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliancejvith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Sery ces. <br /> Job Address Joe=& <br /> <� CitV61-e l Lot Sire/Acreage'-2—P) <br /> Owner's Name 450 Rf Joh& Address Phone 27` 53V9 <br /> Contraclor/`•eme Address /7t� License Ntr�^^t�7231.1 <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION �Y' SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK /0[2 SEWER LINES DISPOSAL FLD. PROP. LINE aiez> <br /> FOUNDATION AGRICULTURE WELL OTHER WELL . :Y 1 <br /> . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # € <br /> 171 Industrial ID Open Bottom 0 Manteca Dia, of Well Excavation a. A <br /> Dia. otwe'll Casing <br /> fEYDomestic/Private >12T Gravel Pack 0 Tracy Type of Casing vCSpecifications A <br /> I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I lfrlgation Z SJ Approx• Depth t I Eastern rj Surface Sea! Installed by CT/L <br /> Repair Work Done IU Type of Pump `��� 'H_p;4"' / , <br /> State Work Dane_S]'EiLY <br /> Clm <br /> „„_ h`•'J� <br /> Well Destruction Well Diaeter , Sealing,Material & Depth i �r <br /> Depth i Filler Material & Depth�--- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION ! I DESTRUCTION I Ir(No septic system permitted if public sewer is-;-•" 'n} <br /> available within 200 <br /> Installation will sgrve: Residence Commercial 7 ,Other <br /> Number of living units: Number of bedrooms" r - <br /> Character of soil to a depth of 3 feet: F `' r _• e _. t <br /> Water'tible depth <br /> SEPTIC TANK. 0 T e/Mf 'f'4 I ' <br /> g Capacity No. Compartments � • <br /> PKG. TREATMENT PLT. ❑ yt l l s 3 k" <br /> d { Method of Disposal <br /> —Distance to-nearest:­Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines t Total length/size <br /> FILTER BED Cl Distance to:nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 `Depth Size �. <br /> � Number, <br /> SUMPS Ul Distance to nearest: Well Foundation Property Line 1 I <br /> DISPOSAL PONDS 0 }� <br /> r <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 /> t Home owner or licensed agent's signature certifies the following: y p' <br /> "I certify that in the performance of the work for which this.permit is issued, !shall not r <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring of 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•tb workman's compensa- <br /> tion laws of California." <br /> The applicant must calf forII required insZ7 �0,0pections: Complete drawing on reverse side. tom' <br /> Signed X ?_ <br /> • Date: z-` 7— g <br /> Title: ... I: <br /> r ENT USE ONLY ! , <br /> Application Accepted by Date #Area_ __ 1 <br /> Pit or90 Inspection by Date Final Inspection by ' Data <br /> Additional comments: <br /> 1 <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Servicesv <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATEPERMi7'NO. <br /> EH 1321 IREV.I M5 1 EH <br /> i!•26 °�+V etjV I35� fi12 . <br /> -�; `" <br />