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E <br /> APPLICATION FOR PERMIT <br /> z = <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> kBMIT EXPIRES 1 YEAR .FROM DATE SD <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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 3 /y �G 411 City �� r Lot Size/Acreage J �� <br /> Job Address . <br /> Owner's Name <br /> /f/,t? Address S.d/0 Phone3 <br /> ,� 3 33 9' y�� <br /> Contractor,rS�-/� �/2. —Address!''y (,�G1C r!70 _- License fVo,3 7 � Phone <br /> TYPE OF WELL/PUMP: NEW WELL�@e- WELL REPLACEMENT 11 DESTRUCTION 0 Out of Service Nell ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR DOTHER C1 Monitoring Nell ❑ <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK A-0 J _ 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 /> dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '� Dia. of Well Casing <br /> 7 ")-Casing Specifications <br /> D estic/Private Gravel Pack ❑ Tracy - YP <br /> Public I:1 Dthe�,. Cl Delta Depth of Grout Seal Type of Grout C� 1 <br /> i I Irrigation 3 C_O.Approx, Depth I I Eastern Surface Saul Installed by <br /> Repair Work.Done 0 Type of Pu1.mp U49 H.P. - - _,.— State Work Done r CAJIV <br /> Well Destruction ❑ Wall Diameter Sealing Material & Depth , <br /> Depth Filler Material & Depth <br /> s. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) - <br /> I` lnstillation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:. - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well =Foundation Property Line <br /> LEACHING LINE L-1 No. &:Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line s <br /> SEEPAGE PITS I I Depth l .` Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 01., - <br /> I 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, l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's airing or sub-contracting signature <br /> certifies the following: "I certify that iri 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." T <br />( The applicant must all for all r aired inspections. Complete drawing on reverse side. <br /> 1 Signed Title: Date: 3 <br /> FOR PARTMENT USE ONLY t <br /> a-�; - <br /> f Applicatjon Accepted by Date fee <br /> _ A <br /> A <br /> w <br /> Pit o Gro t Inspection by Date ­t2-� Final Inspection by Date?-��'�� <br /> A Additional Comments: <br /> i <br /> Applicant - Return all copies to: Sen Joaquin County Public Health 4 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton..-CA 95201 <br /> INFEE <br /> OLtNT DUE AMOUNT REMITTED CASHC"8 RECEIVED BY DATE PERMIT <br /> NO, <br /> EK 13.24 Ir1EV.1/n5Y <br /> EH 74-I6 V 7- <br />