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w-1 <br /> a; C°� APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ZS 3 0 —ru—ZLy & City Lot Size/Acreage <br /> Owner's Name .s ��^� Address Phone7Z7"" S0 S� <br /> Contractor . l r�!?JY'S' Address . O g,7 License No �73� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ti WELL-REPLACEMENT ❑ DESTRUCTION 0 Out of Service We11 ❑ <br /> PUMP INSTALLATION '�� SYSTEM REPAIR Q OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> • b"- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavati6 ZDia. of Well Casing <br /> ;k'Domestic/Private 'Q'Gravel Pack E3 Tracy Type of Casing wC Specifications <br /> I"I Public C] Other n Delta Depth of Grout Seal S Type of Grput__—C C/1tc� <br /> I I Irrigation 3` ?.Approx. Depth I I Eastern SuPce Seal Installed by —Co A-*�AL.A¢.J!?!- <br /> Repair Work Done 17 Type of Pump 27t H.P. Z State Work Done' pL—NS �ENfwS/_ <br /> Well Destruction ❑ Well Diameter Sealing Material b Depth t j <br /> Depth Filler Material 3 Depth 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I, �`°�.. Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg .—____ Capacity T� No. Compartments <br /> PKG. TREATMENT PLT. ❑ v�, Method of Disposal <br /> Distance to nearest: Well 'Foundation Property Line I <br /> i <br /> LEACHING LINE ❑ No. & Length of lines t/~� Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> } <br /> SEEPAGE-PITS` -I A— <br /> —�--�--- <br /> Depth' Size- '"�l Number <br /> SUMPS Ll Distance to nearest: Well'i%Foundation + Property Line I *f~ <br /> i <br /> 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, and <br /> rules and regulations of the San Joaquin County <br /> 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 of subcontracting signature i <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 workmawt compensa- <br /> tion laws of California." <br /> The applicant must call tot all squired <br /> inspections. Complete drawing on reverse side. <br /> Signed X__ f Title: Date: S_ <br /> R DEPARTMENT USE ONLY [� <br /> A:Hommenis; <br /> ted by Date ! `f Area <br /> Piction by `� Dates-2/�'+/ Final Inspection by DBte- <br /> 's <br /> A `.G (a <br /> Applicant •- Return all copies to: San Joaquin County Public Health i <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE IhN`FO AMOUNT <br /> �yDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-I4tREV.tiK51 w� I��,w �,�^L <br /> CH 54-26 J✓✓✓ ��JJ [[ no <br />