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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 /> RES 1 YEAR FR M DATE <br /> x (Complete in Triplicate) <br /> f <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application Ye made in compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 00 ca City _1yL4C!f Lot Size/Acreage t 4- A-c-tzES <br /> Owner's Name EL(ACOE Ttty Lc(14 Il.B.TIDIZKrAddress P.0 . P 0 3 Opo$ r SThcAk[g A, CA Phone -8 6 t <br /> t <br /> i <br /> Contractor QFLr2­4 E kd'.ue"r.o.c Address_2.825 G. MIY2X _ License No.CS15122.1oEs Phone t2 <br /> TYPE OF WELL/PUMP: .. NEW WELL. ❑ . _ - WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ INonitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANKS 14A " SEWER LINES >50' .._ DISPOSAL FLD. MA PROP. LINE <br /> FOUNDATIONAGRICULTURE WELL OTHER WELD lOO r PITS/SUMPS AA_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ O r` <br /> pen Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing <br /> � <br /> n Domestic/Private ❑ Gravel Pack I 0Tracy Type of Casing v Specifications_54Ak= Al2 <br /> I't Public 171 Other fl Delta Depth of Grout Seal Ld Type of Grou <br /> I I Irrigation 1d.Approx. Depth I I Eastern Surface Seal Installed by tJ CKARL <br /> Repair Work Done L7 Type of Pump ° H.P. State Work Done_ <br /> Wall Destruction ❑ Well Diameter Sealing Material & Depth <br /> X KQA(Ttr_AAt1 Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ) DESTRUCTION I I tNo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation vA serve: Residence_._,. Commercial_ Other 4 <br /> Number of living units: Numberofbedrooms <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.❑ t 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 newest: Well Foundation Property Line i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl' Distance to nearest: Wali 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 frcensed agent's signature Certifies the'following: "I certify that in the performance of the work for which this permit is issued, 1 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 C&W=la." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> e <br /> Signed 4 Title: v R-• Date: d= — - C99Z. <br /> FOR DEPARTMENT USE ONLY <br /> IW­ <br /> Application Accepted by "" Data 2 Area tA4J� <br /> Pit or Grout Inspection by Date 2 Final Inspection by Data <br /> Additional Comments: <br /> r <br /> Applicant — Return all copies tot San Joaquin County Public Health <br /> Services. Environmental Health Permit/Services <br /> 1601 E. Hazelton Aye.. P 0 Box 20,0 . tockton. CA 95201 y[ <br /> FEE <br /> f NFJvO� AMOUNT DUE AMOUNT REMITTED �iCCK# CEI 8Y DATE nPERMIT-NO. <br /> . EH 17-14 IREV,1/ 31 V' <br /> Eli 7a-1e CW, rJ7 ` 40/ <br />