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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> " ENVIRONMENTAL HEALTH DIVISION r 'S <br /> 1601 E. HAZELTON AVE. , PHONE (209)468—.: <br /> 42Q � <br /> P O BOX 2009, STOCKTON, CA 9520 <br /> PEgMIT EXP RES 1 YEAR FROM DATE ISSUED MAP 2 0 rZ � <br /> ( �1(� NVIRONti� "N AL (•� <br /> S`i2�cC `vE (Complete in Triplicate) <br /> Application is hereby made to Sam Joaquin County for a permit to construct and/or install theri{lf i s rib� �s <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules a> U = >i sf San <br /> Joaquin County Public Health Services. C �3-- 3W•-ZS <br /> Job Address (' City Lot Size/Acreage <br /> Owner's Name k Address — J � !n - . Phone <br /> 7ap <br /> ' LeNoCohtfa-c -v - Address— a " ' .- W04 - <br /> TYPE OF WELL/PUMP: NEW WELL 0 .WELL REPLACEMENT. 0- �, DESTRUCTION ❑ Out of service Well <br /> PUMP INSTALLATION 9 �� SYSTEM' REPAIR,] s OTHER 0 Monitoring Well ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES'=` DISPOSAL:FLU. PROP. LINE <br /> FOUNDATION AGRICULTURE.WELL OTHER WELL PtTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C <br /> Domestic/Private 0 Gravel Pack O Tracy - - Type-of Casing - - 'Specifications <br /> I'1 PublicI I-1 Other f-1 Delta „_Depth of,Grout Seal t Type of Grout <br /> I I trrigation —.Approx. Depth t I Eastern �f .Surface Sealpfn1�alled by <br /> Repair Work Done U Type of Pump State Work Done <br /> Well Destruction ❑ Well Diameter Sealindo <br /> g Material & Depth' <br /> t <br /> Depth 3 <br /> r Filler Material 3 Depth_... 00 <br /> TYPE OF=SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION ( I DESTRUCTION 111No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence./ �`�Commercial— Other S- <br /> Number of living units: /Number oflbedrooms r a t <br /> Character of soil to a depth-of 3 feet: Water table depth <br /> SEPTIC TANK. 01. Type/Mfg Capacity r No. Compartments 99 <br /> PKG. TREATMENT PLT.'0 � N Method of Disposal <br /> ' Distance to nearest: We)%. Foundation Property-Line <br /> LEACHING LINES 0 No. & Length of lines ,� Total length/size + <br /> FILTER BED �\ D Distance to neare 0 Well Foundation k Property Line <br /> 4- <br /> SEEPAGE <br /> SEEPAGE PITS I l,."'Depth Size % Number <br /> SUMPS LI Distance to nearest: Well Foundation. .Property dine <br /> DISPOSAL PONDS 0 � x i <br /> I hereby certify that I have prepared this,,_ <br /> his.,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, 41?�. �4 + f 1. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the-W-drk 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 sub-contracting signature <br /> cartifies the foito • g: "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 o Dia." 1 <br /> The applic t_ t call.for-all_r aired-ins tions.-Complete drawing o -ev se-side. — <br /> Signed X Title: Date: <br /> i <br /> FOR DEPARTNIENT USE ONLY ) <br /> Application Accepted byDate Area <br /> Z i- <br /> Pit or Grout Inspection by i t Date Final Inspection by Date <br /> Additional Comments: <br /> i + f I <br /> Applicant - Return all copies to: Sau Joaquin County Public Health r <br /> Services, Environmental Health Permit/Services <br /> 1661 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t <br /> FEE A OUNT DUE _AMOUNT REMITTED CK RECEIVED BY j DATE I PERMIT'NO. <br /> INFO CASH <br /> . EH13-24(REV,I/Al S) ..C'7 + �^f � `LJ <br /> EH 74.2e r VV <br />