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APPLICATION FOR PERMIT 0 <br /> SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES � . 0 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PRMIT__EXPIRES1 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 CountyPublicHealth Services., <br /> Job Address _ 1f SPC[,(r i City 5 foLk hklLot Size/Acreage <br /> Owner's Name ANC AZQ0±1001,9"/ Address Ca 4+✓ .1-1w4ow0od ,� CIC.iM Phone 1- O Z <br /> Contractor ��'� d s t Address Le&4' 404 &Wkkicense No. � ���>l Phone <br /> TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION �11 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS S <br /> Cl Industrial ❑ 6pen Bottom ❑ Manteca Dia:of Well Excavation x i . Dia. of Well Casing <br /> r <br /> l"omestic/Private *-Gravel Pack ❑ Tracy Type of Casingy Specifications <br /> I'I Public f.7 Other F1 Delta Depth of Grout Seal. Type of Grout Enh4a1 �2 <br /> I i Irrivation Approx. Depth I I Eastern Surface Seal installed by ' <br /> Repair Work Done ❑ Type of Pump ahrt�. H.P, 3 $tat_e 1<llork-Done= <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth,_-, y r <br /> Depth a Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlAODITION i I_DESTRUCT.ION I 1 lido-septic system permitted if public sewer is <br /> , r t available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> // <br /> Number of;living units: Number of bedrooms r <br /> Character`of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK -1 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATME T PLT. 0 �/ 1.� Method of Disposal <br /> Distance to nearest: kWell Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size r� <br /> FILTER BED rI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line , <br /> DISPOSAL PONDS ❑ <br /> 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 , <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's 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 subcontracting 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 /> tion laws of California." <br /> The applicant uai t call for all required inspe ti ns. Complete dr Ing an reverse side. <br /> Signed Title: —6-041, A , Date: <br /> A NT USE ONLY <br /> Application Accepted by tl.on Date ___(cl~� Area <br /> Pit or Grout Inspection by //�_ p/ n� Data 7 Final (nape//ctian by Dilate <br /> .Additional Comments: L /��� ���7` IGr/ �9f� } t0 <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services r <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> ! <br /> INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-24 IREV.1/A 51 �'�r'��� ' © �" �S� l` '`L� QQ `f C, 70-lel d <br /> EH'14-26 �tJJ. '11V� v —} �- f(� �7- / U <br />