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APPLICATION FOR PERMIT wil- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R E C 1 - ENVIRONMENTAL HEALTH DIVISION AUG f � �� 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 6 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH ZNIT EXPIRES 1 YEAR FROM DATE ISSUEDPERMIT/ `cRVJ ' ,(Complete in Triplicate) .j 4 Application is hereby made,to San Joaquin County for a permit to construct and/or install the work he ein d s i This III application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules ar � 0 P, San' Joaquin County Public Health Services. Schul IVIRONMENTAL HEALTH H Jab Address 147W City Icad Lot Size'/Ac[�e-�8�� M, _ I �3Cilrli i i vi—l�'Ji'v3 J Owner's Name ._@Weirs Illino,j„S Address 14700 Schul Phone 83 -57 Conteactor HOwk_SYStErrts Address 1825 10—sadte Bl License No. Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS '- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private 0 Gravel Pack 11 Tracy Type of Casing Specifications f•, I'1 Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth 11 Eastern surface Seeii installed by 4A Repair Work Done U Type of Pump aWNEI� H.P. State Work Dorie ]sfdllfltrli — Wall Destruction ❑ Well Diameter Sealing Material 8 Depth .Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_-__ Other Number of living units: Number of bedrooms ,1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED CI Distance to nearest: Well Foundation Property Line ray" SEEPAGE PITS 1.1, Depth Sire Number SUMPS LI Distance to nearest: Well Foundation property Line _DISPOSAL PONDS 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 rules and regulations of the San Joaquin county Home owner or.licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person i such manner as to bec me subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the follow' : "1 certify that in ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cai' nia." The applican st call for all r i s clions. Complete drawing on rave e. Title: Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area Pit or Grout Inspection by Date Final Inspection by Date 22 IFQ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERM17'N0. INFO ``ff ��++' 1^ � IVED �y ` EH c3-21 iREV.rin5� "��6- :,J., 7RT-6-ri �p Ot� q0-23t,4 EH 91.2e 7 L T I