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ti APPLICATION FOR PERMIT .- -- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-5420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES _I 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 13111 Z6' City s'TC�" Lot Size/Acreage <br /> Owner's Namej%4� � v Address <br /> Phone <br /> ,, <br /> 'I � f <br /> Contractor e <�<�ff ST Address'_ c� acy / 7�� License No.3?nFs, Phone33y~y�`r <br /> TYPE OF WELL/PUMP: NEW WELL,;M. <br /> WELL REPLACEMENT DESTRUCTION L1 Out of Service Well 0 <br /> PUMP INSTALLATION. f SYSTEM REPAIR El OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION .AGRICULTURE WELL. OTHER WELL 1[ C� PITS/i MPS <br /> i <br /> INTENDED USE' --TYPE-OF-WELL--PROBEEMAREA`"CONSTRUCTI"ON-SPECIFICATIONS"" <br /> C] Industrial ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation . L Dia. of Well Casing <br /> Domestic/Private Gravel Pack 13 Tracy Type of Casing.. 1494--OV� Specifications �—YJO <br /> 1'1 Public C7 Other rl Delta Depth of Grout Seal Type of Grout__C 4­40—t-A- <br /> I I Irrigation y _..Approx. Depth I I Eastern Surface Seal Installed by CA Z=T ---n►L <br /> 'Repair Work Done U Type of Pump S t✓e H.P. _ --%-- _ State Work Done ASA,9a 00, 1�1149 <br /> Well Destruction ❑ Welt Diameter Sealing Material & Depth <br /> Depth ti fl Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION']-I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other _ <br /> Number of living units: Number of bedrooms I <br /> / t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg { f Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ a Method of Disposal <br /> Distance to nes est: ' Well #' '_ ?Foundation I 111,roper4y,Line I <br /> ' <br /> `t hb <br /> # <br /> LEACHING LINE 0 No. & Length of lines Total length'/size <br /> FILTER BED C] Distance to nearest: Well Foundation---I Property Line <br /> v� # k.., <br /> SEEPAGE PITS 11 Depth ~j Site Number I. � <br /> SUMPS Ll Distance to-nearest:? Well Foundation t •s Property Line <br /> w <br /> DISPOSAL PONDS ❑ _. � ,_,.•�, <br /> I hereby certify that I have prepared this•8pplicati6n and that the work will be done"•iri'eccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin`County .)ti, ; .r <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 /> {} } <br /> The applicant must all for all reJfired inspections, Complete drawing on reverse side, r. •- f{ � <br /> Signed X_ Title: �J 1�+� , e ! <br /> - _ -- Date: <br /> R <br /> FITMENT USE ONLY <br /> Application Accepted by L9�r - Date •`Area { <br /> Pit or Grout nepection Dates_-- 4 Final Inspection by "` Date <br /> Additional Comments: f <br /> �6s' <br /> Applicant - Return all copies to: San Joaquin County Public Health e <br /> Services, Environmental Health Permit/Services GU,)"'e r _hl L-CO� OIL U¢e2a rcn�e <br /> ;1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> EE CK 0 <br /> IEEH 13.24 FO ^AMOUNT DUE AMOUNT REMITTED cob-) <br /> RECEIVED BY DATE ] PERM17'NO. <br /> EH i�-�tREY.t n slee= �j t� y 3"l O cG b-) 1 r 1 eG� ��'� { �� I� <br />