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t APPLICATION FOR PERMIT V <br /> i v V <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 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 Public Health Services. <br /> r <br /> Job Address 3 7 r City �`� Lot Size/Acreage <br /> Owner's Name C.«�Of.�� Q <br /> AddresPhone L 3 /�SZ- �� <br /> Contractor Address 'sss✓fO� �7� License No �73+9 SPhone?3 -y7 <br /> TYPE OF WELL/PUMP: ; NEW WELL WELL REPLACEMENT O DESTRUCTION Out of Service well ❑ <br /> PUMP INSTALLATIOf+1�I!5 SYSTEM REPAIR 0 OTHER © Monitoring well U <br /> DISTANCE TO NEAREST: SEPTIC TANK _!/s1 _� SEWER LINES DISPOSAL FLD. S PROP. LINE t/S_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA COfVSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation Dia. of Well Casing <br /> S Domestic/Private Gravel Pack L7 Tracy.. Type of Casing VC Specifications <br /> i'I Public is Other �'-" f� Delta. a Depth of Grout Seal _-j0 a SpeTypfi tionsGrou <br /> I I Irrigation _..ApproK, Depth I I Eastern >" Swiace Seal Installed by /LC <br /> Repair Work Done U Type of PumpvQ _. H p / -LY — State Work Done �73G� <br /> Welt Destruction O Well Diameter Sealing Material & Depth i <br /> Depth ` �Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION t I DESTRUCTION I I (No se <br /> , I. <br /> ptic system permitted if Public sewer is <br /> h t� { available within 200 feet.l <br /> Installation will serve: Residence-I Commercial_ Other <br /> Number of living units: -� Number of bedrooms <br /> Character of Boll to a depth'of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg � t Capacity No. Compartments <br /> PKG. TREATMENT PLT. C7 ` ' <br /> { _ _ Method of Disposal M <br /> Distance to nearest: w Well Foundation Property Line <br /> S � <br /> LEACHING LENS 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distanc ` <br /> e to nearest., Well - Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth I I Size } Number <br /> SUMPS Ll Distance to nearest; Well Foundation Property Line <br /> DISPOSAL PONDS 0 + <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 __ _r <br /> Home owner or licensed agent's signature certifies th'e follo <br /> employ any person in such manner as to become subjecwing;"i'certify that in tfie performance of the work for which this permit is issued, I shall not <br /> t 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 forwhich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." i <br /> The applicant must call for all required inspections. Complete drawing on reverse side, <br /> Signed <br /> Title: Date: <br /> ENT USE ONLY <br /> Application Accepted by Date 3� <br /> Area <br /> Pit or Grout Inspection by� ' Date Final Inspection by <br /> Dat <br /> Additional Comments.- <br /> Applicant <br /> omments:Applicant - Return copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services. <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> s <br /> FEE DUNT DUE AMOUNT REMIgTCA$HCK <br /> INFO p� RECEIVED BY PATE PERMIT'NO. <br /> j EH 13-24 EH ti.2e IREV.t�KSI fO ���J.�� 77--5-1!/ � <br /> ( (f(J <br /> �/ 7 a—?� <br />