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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 /> PMIT EXPIRES 1 YEAR FRQM 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 eowliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health.Services. <br /> Tn� <br /> Job Address -4� qL*ifiI1 t`00- City 70, Lot Size/Acreage f/3 <br /> 59,P-0 Sia h e-raie, i i(-� 3t o <br /> �• {P1ea$a v�h&, , 0A _ ��5�$-- — Phone 0- 63- A711 <br /> } �,�Oser's Name Or Address .TT G54gV <br /> ��haaAddress Licenses-Ne. P <br /> n <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1:1 DESTRUCTION El Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p 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 p� <br /> `f 7 Industrial D Open Bottom 0 Manteca Dia. of Well Exc ation �� Dia. of Well Casing <br /> C.] Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> I'i Public �.Ofher n Delta Depth of Grout Seal o-3 Type of Grout <br /> ••L�TJ <br /> I I Irrigation c.Z� Approx. Depth I I Eastern Surface Seal Installed by t , <br /> Repair Work Done L] Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ! I DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.)Installation will serve: Residence T Commercial_ Other <br /> Number of living units: Number of bedrooms V <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. ❑ 1 s1f1'LDP�� <br /> Distance to nearest: Welt Foundation ProperRMEWED- <br /> LEACHING LINE ❑ No. g Length of lines Total length/MAY <br /> FILTER BED D Distance to nearest: Well Foundation FIrtJ0AQ1 I IN OIINTY <br /> PUBLIC HEALTH SERVICES <br /> SEEPAGE PITS 11 Depth Size NuPJY}RONMENTAL HEALTH DIVISION <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 C` <br /> Home owner or licensed agent's signature certifies the following; "f 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 f r all r qui(ed inspections. Complete drawing on reverse side. <br /> Signed X Title: !� w Date: <br /> OR (DEPARTMENT USE ONLYrJQ•0Z) <br /> Application Accepted by Date Area LL-- II VV <br /> Pit or Grout Inspection by Date Final Inspection by r Dat <br /> Additional Comments: b dQ G1 `T 1+ V'lh • <br /> Applicant - Return 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 /> EE 11 <br /> INFO AMOUNT DUE AMOUNT REMIT-TED ASR tt�y�R�ECEIVED BY 57-4:;,.q3 <br /> rJ DATE +/�PPERMIT'NO.. <br /> . EH 1324IAEV.r/N ' .v� �!. Q" VOM �' L ✓ •r(�•q I0"DS1y <br /> EH:4.20 <br />