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Lei 1 0 APPLICATION FOR PERMIT OSeA Nf <br /> 3 ���• <br /> 3-3 Y <br /> kLJa,, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> LG,y� r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> rrSc ��(c- C�ip� ar P O BOX 2009, STOCKTON, CA 95201PRUIT ' 3 <br /> 1�3 ! L �f dGlc r lG�p aI <br /> EXPIRES.1 YEAR FROb6 PATE ISSUIM <br /> (Complete in Triplicate) <br /> 2-- <br /> tion <br /> is hereby made to San Joaquin County for a permit to construct and/or install the work herein describe(5. _ This i <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. nn I <br /> Job Address S „ pity Lot Size/Acreage <br /> ' L A Phone, <br /> Owner's Name Address <br /> - G1!`3�� <br /> Contractor Address License No. Phone , <br /> TYPE OF WELL/PU NEW WELL 0WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well C1 <br /> PUMP INSTALLATION El SYSTEM REPAIR O OTHER C3Monitoring 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I— — r._ -,., .�-. <br /> f:1 <br /> Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing Specifications <br /> Cl Public : .x.11.Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx F Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. s` LL State Work Done 1 <br /> Well Destruction ❑ Wait Diameter <br /> -Sealing Material•&•Depth! <br /> Depth Filler Material B Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l 1-DESTRUCTION 1 I iNo septic system permitted if public sewer is <br /> f Q available within 200 feet.) _ <br /> Installation will serve: Re idence_ Commercial__ Other O ` h .I w __✓` I <br /> Number of living units: 77 Numbe�f bedrooms i �+I C��^ VI �I�! � a <br /> Character of of 3 feet: --- Water table depth <br /> SEPTIC TANK Itod to a d�thType/M1 �oa _ F'�I I �- pacrty �'S�- -- No. Compartments <br /> A g <br /> PKG. TREATMENT PLT. ❑ ,� _ Method of Disposal I� <br /> Distance to nearest: Well Foundation l Property Line' <br /> ID­ f <br /> LEACHING LINE No. & Length of lines Total length/size t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue Number ' <br /> �SSUMPS 0 Distance to nearest: Well Foundation Property Line <br /> `v 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, andl <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 /> r1 employ any person in such.manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> f 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 st call for requir InsPections, Complete drawing onreversesidA�e. �} <br /> Signed X Tiils:, & t�IL � pate: i ` f�� (w✓ _ <br /> r <br /> ' FOR DEPARTMENT USE ONLY <br /> Area``.,1 S'� '✓ <br /> Application Accepted by. Date , <br /> Pit or Grout Inspection b Date Final Inspection b Date <br /> Additional Comments: 6 r h` ���rrr� �C�u I f p` f,�s 1 r-k}r .dam• + + _ <br /> Applicant -'Return all.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 Y <br /> k FEE AMO NT DILE AMOUNT REMITTED �A RECEIVED BY DATE PERMI7'NO. <br /> f INFO <br /> . EH 13-24lREV.+/K5f <br /> EH 74•20 <br /> t � , <br />