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r I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> pFJW1T EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jab Address City Lot Size/Acreage <br /> Owner's Name C►-` U� Address r Phone 91IS !"] <br /> 41 1 <br /> Caniracior S"�� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ -Monitoring. Well L <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES + _ DISPOSAL FLO. PROP. LINE <br /> f:. <br /> -FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C? Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f <br /> I'1 Public i-1 Other f"1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ..M.. Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction D Well Diameter Sealing Material & Depth I� <br /> Depth Filler Material & Depth Vi <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i' REPAIR/ADDITION)Q DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet. <br /> Installation will serve: Residence _X_ Commercial— Other <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: e-k�`A. j —Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ s Method of Disposal <br /> - Distance to nearest: Well �'`t"�"Fpu+ ation Property Line tl� <br /> LEACHING,LINE' 0 No. & Length of.lines A. Total length/size A0 X 2� <br /> T R BED Distance to nearest: WeII '` Foundation Property Line <br /> L E <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS, x LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> yf 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 such manner as to become subject to workman's compensation.laws of California." Contractor's hiring or subcontracting 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 />{ The appG an must cats for a required inspections. Complete drawing on reverse side. <br /> Signed Title: ._ + r' + ! Date: <br /> l "FOR DEPARTMENT USE ONLY r 4 <br />{ Application Accepted by Date Area ( <br /> Pit of Grout Inspecition by Date Finel4Inspection by Date�a <br /> Additional-Comrnents: <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 /> f FEE AMOUNT DUE AfilOUN7 Rt MITTEOSH RECEIVED BY GATE PERMIT N0. <br /> 'INFO �r� f/�� <br /> . EH 13.241REV.I/HSI // �, ov ry 5f-0-sr V D <br /> I EH 84.26 <br />