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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE, , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PER_MST_EXPLRES- 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 corupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin CounQty Public Health Services. <br /> JL <br /> Job Address a-r S_ /�'t4A45:5_"'�`" 0-4 City �''�^�`f Lot Size/Acreage <br /> ^ �N1+ �T 1 � � 4 — � 1 Phone6 k-72 �i <br /> Owner's Name 10 rt Address r <br /> Id . <br /> If <br /> Contractor � �[ -�/ Address l� {r License No, 6,)-322_ Phone Z a `�- <br /> TYPE OF WELL/PUMP: !p NEW WELL: © WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION�O SYSTEM REPAIR © OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF'WELL PROBLEM AREA ,CONSTRUCTION SPECIFICATIONS <br /> f--1 Industrial ❑ Open Boitom ❑ Manteca /:Dia. of Well Excavation Dia. of Well Casing <br /> l; Domestic/Private ❑ Grave) Pack ❑ Tracy *` Type of Casing Specifications <br /> C1 Public 1-1 Other Fl Delta F epth of Grout Seal Type of Grout <br /> I I Iffigation �.tApprox. Depth I I Eastern 4 Surface Seal Installed by <br /> Repair Work Done YO' of <br /> Pump H.P. +{ State Work Done — <br /> Wall Destruction ❑ Well Diameter Sealing Material & Depth <br /> '��,.. De th i Filler Material & Depth <br /> p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADO TIOfV,I,I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> II 1'( available within 200 feet.) <br /> Installation will serve: Residence { Commercial— Other <br /> Number of living units: Number of bedrooms 1 <br /> f - <br /> Character of sW to a depth of 3 feet: Water table,depth <br /> SEPTIC TANK. No. Compartments <br /> PKG, TREATMENT PLT. ❑ �� l`` Method of Disposal <br /> Distance!to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines 1 Total length/size <br /> FILTER BED n Diistance'to nearest: Well Foundation Propeny Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS L) Distance-tb nearest: Well`" Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and thatthe 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 agents 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 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 to workman's compensa- <br /> lion laws of California." Ii <br /> The applicant ust cal for all re uired inspections. Complaie drawing on reverse side. <br /> o <br /> Signed X—_ tle: 1_(J_" 17 Q <br /> l .� _ Date: <br /> ® FOR DEPARTMENT USE ONLY A <br /> Application Accepted by . . . _�p�JU.e/ Date v Area 1 <br /> Pit or Grout Inspection by Date Final Inspection tnf l 1 Data <br /> Additional Comments: <br /> ll. <br /> Applicant - Return all copies to: Ban Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. <br /> . EN 2�IREV. r x si <br /> A- f-7-70 <br /> h r ! `'] lJy�— <br /> �� ry <br /> EH 41.2p / a [J L� <br />