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3:30 <br /> APPLICATION FOR PERMIT <br /> S`JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 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 Coun-ty <br /> r�P)ublic Health Services. - <br /> Job Address yIV ., L-4 a /Z � -� City �r G[ c= Lot Size/Acreage LO D �L•� <br /> Owner's NameeYN.5 RvbQ Address 5 Z-(-'m Phone y D �7 <br /> Contractor "e_e,rD5 ddress c7 cense No 3 03Phone f_j <br /> TYPE OF WELL/PUMP: NEW MLL ❑ 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 111 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public El Other n Delta Depth of Grout Seal Type of Grout <br /> ... 1 I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No 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 bedrooms1. <br /> Character of soil to a depth of 3 feet: _ _e, T,--)dWater table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> n <br /> SEEPAGE PITS _�V Depth _Size _ Number <br /> SUMPS LI 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 laws of California." <br /> The applicant must call for allre r spectio s. Complete drawing on reverse side. <br /> Sign Title: <br /> / '-[-✓1-e.L Date: <br /> P� FOR DEPAR MENT USE ONLY <br /> Application Accepted byI JSIL Date Area <br /> Pit or Grout Inspection byDate Final Inspection by a- Date 7/2 �j0 <br /> Additional Comments: r,I-s 4_4�/ vee <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services �l <br /> �- . 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH /RECEIVED BY DATE PERMIT'NO. <br /> �EMt3•24(AEV.rins) 7 r V �"�b ^"�(� <br /> EM:1.26 l./ <br />