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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- 95201 <br /> PERM <br /> IT 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.ccuipliance 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 �f�� G� !V -Z,I/fes/y t✓ l� � City 1C C. Lot Size/Acreage <br /> 1 r <br /> Owner's Name �S--GFr� Lc•-�7r T�11[CriT� Address 4142 0 Phone <br /> Conttaclor Address d- License Noo2P—��=�Phone <br /> ' <br /> TYPE'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PAOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> R n industrial 0 Open Bottom. 0 Manteca Dia. of Well Excavation .Dia. of Well Casing <br /> Cl Domestic/Private 0 Gravel Pack' ❑ Tracy Type of Casing Specifications <br /> 4 F <br /> _ <br /> I'l Public, 1.1 Oiher 171 Delta Depth of Grout Seat Type of Grout <br /> I I lrrigation _.-Approx. Depth I i Eastern Surface Seat Installed by <br /> Repair Work Done L] Type cif Pump H.P. State Work Done <br /> Well Destruction 0 Wait Diameter Sealing Vlaterial A Depth <br /> r ` Depth - Filler Miaterial i Depth 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION RE PAIR IADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> r available within 200 feetA <br /> Installation will serve: Residence_ Cbmmercial_ Othor <br /> Number of living units: Number of bedrooms <br /> ' Character of soil to a depth of 3 feet: _ Water table depth <br /> # SEPTIC-TANK. 0 TypelMfg - Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of�Disposal <br /> Distance to nearest: Wep�CtZ Foundation�'Property Line <br /> LEACHING LINE r F <br /> No. & Length�,oQines � Total length/size � �r <br /> FILTER.BED Ef Distance to nearest: Wail Foundation Property Line <br /> FSEEPAGE PITS 1 I Depth <br /> SUMPS . Distance to nearest: WeliaV4r2270- Foundation,—_19 Property Line. <br /> DISPOSAL PONDS . O <br /> J <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> F rules and regulations of the San-,Joaquin County state laws, and <br /> Home owner of licensed 4gent's-signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not <br /> F" , <br /> employ any person in ouch 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 tha.l in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion ltlws;of California.' <br /> The as. plicant must call for all r ired 'inspections. Completa.drawing on reverse side. <br /> Signo Title' Lr Date., <br /> { -F6R DEPARTMENT USE ONLY <br /> Application Accepted by ' Date ! 2"2— �{ <br /> Area <br /> . i <br /> Pit or'Grout Inspection_by Date ' Final Inspection by Date 2 y <br /> Y, <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services i <br /> 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT,DUE AMOUNT REMITTED CK RECEIVED BY PATE <br /> .' CASH i PERMIT N0. <br /> . EH 43-24(REV,lJral .� - � ■ r f ._.,... -.� Y � � - .. i <br /> EM;/-26 <br />