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. APPLICATION, FOR PERMIT <br /> � ,. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 'fit <br /> ENVIRONMENTAL HEALTH DIVISION .. <br /> EN <br /> 1601 E. HAZELTON A'VE. , P130NE .(209)468-3420 <br /> P 0 BOX 2009,• STOCKTON, 'CA 95201 ARR�-f' = <br /> r r RYTT EXPIRES 1 YEAR wor%U DATEID <br /> ENVIRONMETAL HEALTH <br /> (Completei.n Tri.plicate) PERMIT/S RViC <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.. and 1$62 and the Rules and Regulations.of San <br /> Joaquin County Public Health Services. `�f���U; ` .r a.. <br /> �ff / C ! Lot Size/Acreage'. Z'/� v'= i <br /> Job Address . LL 55 i City w <br /> Phone Z/.N�9I <br /> Owner's Name Address , . <br /> ... _ <br /> Address License No. d -Phone <br /> i <br /> Con4i2ctor <br /> f WELL REPLACEMENT ❑ DESTRUCTION ❑ Out aP Service Ne11 ❑ <br />' t,.TYPE OF WELLIPUMP: NEW WELL ❑ ,_ -< '- <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ - OTHER ❑ Monitoring Well'"d <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP:LINE <br /> FOUNDATION AGRICULTURE WELL,±=:j" "`OTHER WELL= ' = PITS7SUMPS _ <br /> _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W µ <br /> pia. of Well Casing <br /> ;^0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation g <br /> Cl <br /> Domestic/private ❑ Gravel Pack C3 Tracy t Type of Casing Specifications: <br /> j fl Delta Depth of Grout Seat - Type of Grout <br /> f I'I Public M Other _- - .-. -- <br /> I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by -� <br /> } State Work Done <br /> -•.-Repair Work Done L3 Type of Pump N.P. {` <br /> Sealing Material & Depth <br /> ¢ Well Destruction ❑ Well Diameter <br /> Filler Mat S Depth <br /> Depth V <br /> TYPE OF SEPTIC WOflK; NEW INSTALLATION I i REPAIRlADDITI N I ESTRUCTION I I INo septic system permitted it public sewer is •. <br /> available within 200 leet.l ` <br /> Installation-will serve.- Residence Commercisl � <br /> . , <br /> -. AM <br /> Number of living units: f Number Brooms •--.� <br /> ' Character of soil to a depth of 3 <br /> Water table depth ' ' <br /> TANK CST a/Mfg Capacity No: Compartments' ., a <br /> SEPTIC YP <br /> Method of Dispossi <br /> r !'PKG..TREATMENT PLT.❑ k.. •: T r:. �; .. . <br /> ' Foundation Property Line <br /> Distance to nearest: Well <br /> ' Total length/size 7 <br /> 'LEACHING LINE s No. & Length of <br /> f tines J <br /> i t / <br /> FILTER BED ❑ Distance to nearest: Well L r Foundation a�� — Property Line ' ; i <br /> SEEPAGE PITS !� Depth Size _ Number r ;._ { <br /> _ s�. 0 -.� <br /> t SUMPS t S LI Distance to nearest: Welt . Foundation- �d Property Line—' <br /> " <br /> -rDISPOSiAI PONDS <br /> ' l I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ' ruses and regulations of the San Joaquin County t <br /> Home owner or licensed agent's signature certifies the following: "I certify that In the perlormance of the work for which this per <br /> is issued, I shell not. <br /> nsation laws of California." Contractor's hiring or subcontracting signature <br /> Temploy any person in such manner as to become subject to workmen's compe <br /> f <br /> �j'. certifies the fallowing:"I certify that in the performance of the work for which this permit is issued,!shall employ persons subject to workman's Cgmpense• �. <br /> tion laws of California. 4 <br /> tions. Complete drawing on reverse side. <br /> .:.,-",The applicant Myst call for.all re hirednspec <br /> ;Signed Tide: Date: <br /> X <br /> ~ F R DEPARTMENT USE ONLY..» <br /> a ... Fw �-•--- Area.aAPPlicetion Accepted bDste kn- <br /> s <br /> Pit or Grout Inspection by Date Final Inspection by, Date = <br /> Additional Comments: ` <br /> Appiicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services r l <br /> 1601 E. Hazelton Ave., P 0 Box-2009, Stockton, CA 95201 ! <br /> FEf ?AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE, PERMIT NO. ,­ I i <br /> + _ INFO ' G �1 <br /> k1321f11EV <br /> 1 <br /> 'insr _! _�, �� O �� ell 010. S ' <br />