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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 /> PERMIT EXPIRES 1 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 1862 and the Rules and Regulations of San <br /> Joaquin County <br /> Public Health Services. <br /> Job Address `�J Cs /t/� R ell City S 7 V Lot Size/Acreage <br /> ` - 1 �f <br /> Owner's Name Ste • Address . �,. _ Phone <br /> Contractor�'lS1�L.QaC�i r.�itlxc- Address •-La -, I_ ,+.�U�� License No. _ �j4 Phon a�2 .Z 0 <br /> TYPE OF WELL/PUMP: ,,NEW.WELL.❑—,r.,,,.,o,,,,,WELL•REPLACEMENT,0 ­DESTRU.CTION,D,0_ut�af,-Service We11 [DPUMP INSTALLATION ❑ SYSTEM REPAIR ❑Wj OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTION"SPECIFICATIONS <br /> Ll Industrial --�_.❑-Open Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing -� <br /> Cl Domestic/ <br /> Private Ll Gravel Pack--�,,,, ❑ Tracy Type-ofSCasing Oji Specifications <br /> !'l Public 1.1 Other (1"Dslib-, Depth ci Grout Seal Type of Grout <br /> I I Irrigation ' `�� Approx. Depth l'I Eastern 5urface 5eal'Ins1elled'by <br /> Repair Work"Done 0 Type of Pump t z4 H,P. Slate Work Done_ <br /> Well Destruction ❑ Well Diameter r -Sealing Material & Depth ! / <br /> { Depth ; t Filler Material & Depth <br /> TYPE OF SEPTIC`WORK: NEW INSTALLATION-1 I REPAIR/ADDITIONX DESTRUCTION l I (No septic system permitted6f public sewer is <br /> available within 200 feet.I" <br /> Installation wiil;,serve: Reside nc commercial Oth6l^_ t r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - Water,table depth <br /> SEPTIC TANK. ❑ Type/Mfg r I CapacityNo Compartments <br /> PKG. TREATMENT PLT ❑ 4' i Method of Disposal <br /> Distance to nearest: t.Wel / Foundation ! (Property Line <br /> tLEACHING LINE t.❑ No. & Length of lines Notal length/size <br /> FILTER BEDto, <br /> L) Distance nearest: Well l Foundations Property Line <br /> *)SEEPAGE PITS I') <br /> Depth Size �2_n 3wf Number r `_aw l 6ti7D <br /> "SUMPS I Distance fo,nearest: Well ,1O�r Foundation 6�z Property Line yA <br /> DISPOSAL PONDS ❑ � <br /> 'thereby certify that I have'prepared this application and thi0he work will be-done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County —4- <br /> Home <br /> -4-Home owner or licensed agent's'signature certifies:the following: "I certifohat in the performanc of the work for which this permit is issued, I shall not <br /> employ any person'in such manner as to become subj ci.to workman's.compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work fpr which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Theapplicantkmust for all r ire inspections-Ci5implete drawing on reverse side. <br /> Signed � �. Title: — Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted bye Or Date - `'( Area t <br /> Pit or Grout Inspection by Date Final Inspection bys Date <br /> Additional Comments: E <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P O'Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT No. <br /> INFO tZ=4111111111P CA-S-9 <br /> + EH13-24(REV,t/H51 <br /> EH 94.2e c1 <br />