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3,00 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 O BOX 2009, STOCKTON, CA 85201 <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 nude In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public <br /> Health Services. / av� <br /> Job Address /l7Llit'.B City Size/Acreage <br /> Owner's Name Address � �1 phone 719 <br /> 'i�on(iacta ddress ' < 5e N Phone <br /> -,SYPE-Of WELL U NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION CI Out of Service Well O j <br /> ri PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 f <br /> DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial r ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> — <br /> ['I Public (7 Other fl Delia Depth of Grout Seal Type of Grout <br /> 1 I Irrigation _.Approx. Depth I 1 Eastern Surface Soul Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done— 'I <br /> Well Destruction 0 Well Diameter Sealing Material a Depth i <br /> Depth Piller Material h , <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 1 I REPAIR/ADDITION DESTRUCTION I 1 (No septic aystem'permittad if public sewer is <br /> available within 200 feat.) <br /> Installation will serve: Residence_ Commerolal_ Other <br /> Number of Owing units: _ Number of tfedrooma _ 1 <br /> Character of soli to a depth of 3 feet: ( T Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments +1� <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Wel�_tJ Foundation _ Property Line r. ' <br /> LEACHING LINE 0 No. 8, Length of lines C� ' n. Total length/size f �' <br /> FILTER SED 0 Distance to nearest: Well_ Foundation` LJ Property Line 1 <br /> SEEPAGE PITS I I Depth .Size- ""V- °iNumbtr f f <br /> SUMPS LI Distance to nearest: WOM Foundation--;i2 property Line 1�30 1 <br /> DISPOSAL PONDS 0 <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawa, and <br /> rules and regulations of the San Joaquin County <br /> Boma 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 portion in such manner as to become iubject to workmen's compensation laws of California."Contractor's hiring or subcontracting signature <br /> unifies the folbwing:,'-I candy that in the performance of the work for which this permit is issued,I sha11 employ persona subject to workman's company- <br /> tionkbwa of California."'- I 1-t <br /> Thea <br /> pplicent it It ce r al aqui ode c ctlona. Complet d wire on revery a de. <br /> Vi <br /> Sipn� ✓ Title: w ya Date: <br /> . � ���� DEPARTMENT USE ONLY 1 <br /> Application Accepted by —(31 L�ti„},� <br /> ` Date - Arse G <br /> Pk or Grout Inspsction by - Date Final Inspection by Date G -6 Z O <br /> Additional Commenter <br /> Applicant = Return all copies to: San Joaquin County Public Health <br /> Services, ffitviroomental Health Permit/Serviced / <br /> �.. 1601 B. Basalt= Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> r/� INfO MOUNT DOE AMOUNT REMITTED CAIN RECER/ED BY DATE PERMIT NO. lV4K��i_ <br /> ` .EN 11.24 OfiEw vxm /D <br /> EN 1a.1ti.l vV <br /> i <br />