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3 APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> SAN JOAQUM OOUN�r'�- �ft"U $ S TOCSTON, CA 95201 <br /> MMONMSN' L IEs YEAR FROM $ ED <br /> SPECIAL? <br /> 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 /> Job Address 2(a p � � f�C9l -- - City v1 Lot Size/Acreage <br /> j� f J r,, ,,� f -71 <br /> Owner's Name boyw)CC Jye_r Address !2- y"' �*rw- _-_ Phone 3 <br /> Centractpr C dress Z5"E, S S L��S License No.��'��0 1 Phone 2011%5-971Z <br /> TYPE OF WELL/Pump: NEW WELLk WELL-REPLACEMENT C7 DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Mgnitori Well r}r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -PROP. LINE W 5 <br /> IF FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i=1 Industrial ❑ Open Bottom la Manteca Dia. of Well Excavation tVlt Dia. of Well Casing k <br /> fa Domestic/Private Gravel Pack L1 Tracy Type of Casing Specifications <br /> i'1 Publici 1 pf,C�her Ll Delta Depth of Grout Seal Type of Grout C `t2�1 <br /> - rox Depth I I Eastern Surface Seal <br /> I I Irrigation zs' Installed by <br /> r <br /> Type P <br /> Repair Work Done U T of Pum" H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth <br /> Filler Material & De <br />� Depth P <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I E DESTRUCTION i I iNo <br /> septicsystem stem 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 <br /> Character of soil to a table Water de th of 3 feet: I <br /> pdepth <br /> SEPTIC TANK 0 Type/Mfg r Capacity - No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line C <br /> LEACHING LINE Cl No. & Length of lines Total length/size 1 <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ` 11 Depth ,yt "" Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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, 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 sub-contracting 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 /> The applicant must call for.all <br /> �required inspections. Complete drawing on reverse side. <br /> Signed X Afr1A_ �{ - C s rY_, Title: AM- L`t Ut,L 9_Aa,2_ . Date: Lo/TO Jf.90 <br /> FOR ME E ONLY <br /> Application Accepted by Date `© Z` �v Area �3 <br /> Pit or Grout Inspection((by 3 Date Final Inspection by Date <br /> Additional Commentsf� 1tJ i RICY4 <br /> ] Yo"Al e-8 \`t <br /> j <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> t + EH13-24 fR V.v?+Sl <br /> EH i4 <br />