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k . ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f _ ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> ` P O BOR 2009, STOCKTON, CA 95201 <br /> F <br /> ��IT EXPIRES 1 YEAR FROM DATE ISSUBP <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 campliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health[�Services. <br /> Job Address% J # City Lot Size/Acreage Q C!1 V <br /> v i <br /> Owner's Name p lI/ �I�6�Addrss 11 <br /> hone <br /> Contractor ; - Address ` <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM EPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE f <br /> FOUNDATION JL JL <br /> LL OTHER WELL PITS/SUMPS_' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTiON SPECIFICATIONS <br /> F1 Industrial ❑ O i <br /> pen Soitom ❑ Manteca of Well Excavation Dia.' of We)I,Casing <br /> ❑ Domestic]Private 0 Gravel Pack ❑ Tracy Typ of-Casing Specifics[ions "} <br /> I'] Public ill Other { n Delta Dept of Grout Seal Type of Grout to t <br /> I I Irrigation Approx. Depth I I Eastem Surface eal Installed by ` + �`f <br /> Repair Work Dane L7 Type of Pump .P.. State Work Done _ ---------t� <br /> Well Destruction ❑ Well Diameter { Sealing Material & Depth # '\ <br /> Depth t f Filler Material & pt <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION I i DE TRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial ther e <br /> Number of living units: Number of bedrooms �. x <br /> Character of soil to a depth of 3 feet: C '�— _ Water table depth 0 j <br /> SEPTIC TANK ❑ Type/Mf06 G�.O R'u Capacity_-I fj=Q';,-� No. Compartments o2 <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well-JY4 _ Foundation �� Property Line .� <br /> ..t <br /> LEACHING LINE Cl No. & Length of lines 0 Z w_ Total dlsngth/size 0f <br /> FILTER BED Cl Distance to nearest: Well_,LZZ2 Foundation - fD Property Line <br /> SEEPAGE PITS 11 Depth Size I <br /> Number <br /> SUMPS U Distance to'nearest: Well Foundation� � Property Line ` <br /> DISPOSAL PONDS I] t <br /> I hereby certify that I have prepared this application and that the work will be done in accoFdance'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: } <br /> "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.- <br /> performance hiring or sub conrracting signature i <br /> ceriifiea the following; "I certify that in the performance of-the work for which this permit is issued, I shall empio '' ` <br /> tion laws of California." Y persona subject to workman's compensa- <br /> 7he appiicant us alt for all requir pgctio plate drawing'ori-reverse side. , <br /> Signed X <br /> Title: - - v - Date:,--3 - :a AFD <br /> . R DEPARTMENT USI: ONLY <br /> Application Accepted by -. _ _ s <br /> Dais. t� - Area" r-- <br /> Pit or Grout Inspection by '" -Date Final Insp ction by to <br /> . Additional Comments: <br /> Applicant - Return ell copies to: {San .7oaquin'Co' tun y''Pub is Health `' - -rJ 1)o4,1 QHS IUt Q✓r [/1f t,.t P jY <br /> Services, Environmental Health Permit/Services. <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE tE r~ AMOUNT REMITTEDCK <br /> INFO j-11A <br /> ASH RECEIVED 9Y DATE PERMIT'N0. 3 r <br /> _ _ — _ <br /> a EH t3-24{REV.I I mm n <br /> EH i4.26 t � �V� •�� <br /> ,77777 _ <br />