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APPLICATION -FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E.`I'; HAZELTON AVE. , PHONE (209)468-3420 <br /> r P O BOR 2009, STOCKTON, CA 95201 <br /> EXPIRES 'l 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 campliance 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 tZ City �J'C Lot Size/Acreage <br /> l Mft3 ?` �', p Gr M,- FD 1?d.k /071 S�iry /i�.yr �'c+S'S �APhone "U4' 112-0- '?G <br /> Owner's Name Address �+ -- <br /> Contractor 057_6P-&_6P—G__'�'Si-Wa!Address � �i Floeo_PW-_ �tZP.icense No. 1/�+S d _Phone C13 ! P9-7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well 0 <br /> i PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well :� J' <br /> DISTANCE TO NEAREST: SEPTIC TANK N!� SEWER LINES Id Fr DISPOSAL FLO. !Ua~--- PROP. LINE W 'GG; <br /> FOUNDATION O AGRICULTURE WELLl� OTHER WELL—A21—".. PITS/SUMPSAWAJ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 /' Dia. of Well Casing C* <br /> (a Domestic/Private A Gravel Pack PrTracy Type of Casing U el -__ Specifications <br /> I'1 Public EI Other Cl Delta Depth of Grout Seal �3±o 6 "7- Type of GroutS�/ '�N- U'1 <br /> 11 Irfigation �rApprox, Depth 11'Eastern Surface Seat Installed by �S�C PLLS S�'w'�*P-T M - - <br /> Repair Work Done L3 Type of Pump _AXONE ^' H.P. State Work Done <br /> Well Destruction ❑ Well Diameter -2 Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIFI/ADDITION I I DESTRUCTION I I INo 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 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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 /> 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 law#o1allfoirriia,'" <br /> The appst al f 11 req inspections. omplete drawing onrSigned V Title: Date: 5 3CJ 0 <br /> FOR DEPARTMENT USE ONt;� <br /> Application Accuprud A9M%qVI <br /> Date S �� Area <br /> SAN 3 <br /> RON1 <br /> Pit or Grout Inspection t, p aale -Final Inspection by Date u" 1) <br /> Additional Comments: ��� 1. , + E I <br /> Applicant - Return all copies to. San Joaquin County Public Health fz, <br /> Services;"Envircnmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CCC RECEIVEASHD BY DATE PERMIT NO. <br /> . fM 13.2 IfitV,r I n sl q <br />