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APPLICATION FOR PERMIT <br /> �7/ 2.. <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PFZMIT EXPIRES 1 LEAR 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 trade 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 1/Qo Lu, CiryL4--c- Lot Size/Acreage <br /> Owner's Name Ln Address .4 -RV r ,3 <br /> -- - Phone <br /> f <br /> Contractor Qam __?v Address 2 License No/_�__�_3�Phone cep .yam <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION �`O AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR09LEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C:] Domestic/Private ❑ Gravel Pack 0 Tracy Type e of Casing— Specifications <br /> ('I Public El Other f1 Delta Depth of Grout Se6l Type of Grout <br /> I I Irrigation Approx. pe�h I I Eastern Surface Seal Installed by <br /> Repair Work Done U' Type of Pump' � � � � �, <br /> p 1 �t H.P. State Work Done <br /> Welt Destruction ❑ Well Diameter j Sealing Material Depth <br /> 1 <br /> Depth Filler Material & Depth) <br /> TYPE"OF�SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted it public sewer is G <br /> ` = 1 available within 200 feet.) <br /> Installation will serve: Residence_ Commercia Other , <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: j I i rt <br /> Water table depth <br /> SEPTIC TANK. : , 0 T e/Mf I <br /> �g Capacity No. Compartments <br /> PKG. TREATMENT-PLT, •- S{ Method of.-Disposal <br /> Distance to.nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines �':' , �'' �+ <br /> g. _��� Total length/size <br /> FILTER BED 0 Distance toynearest: Well L,—-",--,Foundation Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size t Number j <br /> SUMPS LI Distance to'nearest: ,Well ' Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> t <br /> t <br /> I hereby certify that i have prepared this application arid.-that the work will be none in accordance with San Joaquin county ordinances, sae laws, and <br /> rules and regulations of the San Joaquin County ; } <br /> Home owner or licensed agent's signature candies thefollowing: "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 Eaws'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/ st c�a I�for a/ll required inspections. Complete drawing o verse side. <br /> 19 <br /> Signed X EM amu! J le: 1p t <br /> Date: j <br /> I <br /> FOR DfiPARTMENT USE ONLY <br /> Application Accep ed by //V Date — ��a Area <br /> Pit or Grout Inspection by Date-- _—� Fine) Inspection b _ G, Date �7 � <br /> Additional Comments: � <br /> Applicant — Retuzv 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH fiECE1VED SY DATE PERMIVN0. <br /> . EH 13-21 MEV.tihs1 lcl2 l II <br />