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APPLICATION FOR PERM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> REGI <br /> HEALTH DIVISION D- <br /> F-NVIRONMENTAL <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MAY 1 1400n <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> tNV1RQNMEN IAL HEATH <br /> RE YE PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application Is hereby made to Sax Joaquin County for a permit to construct and/or install the work herein described Thia <br /> application is made in compliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> .lob Address S <br /> m City mAWt'Er fl Lot Slxc/Acreage ' 1ZA A C Wit= <br /> I <br /> Owner s Name Address fz�,&iYY4—� _ Phone <br /> Z-ql ASL*iaA lHo -1415' <br /> Contractor +tom Address License No SIttoSPhone U - q <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well I-) <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK A SEWER LINES ^' 9�r _ DISPOSAL FLD AA PROP LINE '"^IOC <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_f-� PITS/SUMPS �A <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industnal �❑ Open BottomanC teca` Dia of Well Excavation_-8 Dia of Wall Casing r� <br /> FJ Domestic/Private E Gravel Pack ❑ Tracy Type of Casing -_PV t Specifications <br /> I 1 Public 1-1 Other n Desta Depth of Grout Seal - 13 <br /> t Type of Grout r <br /> I I Iriigauon 2DApprox Depth I I Eastern Surface Soul Instilled by C< <br /> Repair Work Done U Type of Pump H P State Work Done <br /> Well Destruction D Well Diameter _�- Sealing Materiel i Depth lk-Z p y410_ <br /> Depth 3rd F11ler Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I i INo septic system permitted it public sewer is <br /> evadable within 200 feet } <br /> Installation will serve Residence. Commercial_._. Other <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 Type/Mfg Capacity No Compartments <br /> PKG TREATMENT PLT 0 Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE ❑ No 8 Length of tines Total langth/size <br /> FILTER BED Ll Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS LI Distance to nearest well Foundation Property Lena <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 /> I 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 workmen 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 persona subject to workman s compensa <br /> I lion laws of California " <br /> The applicant must call for all requi dinspections Complete drawing onreverseside <br /> Signed X R n R 1 , o46A-0-01 Title 14Data <br /> EPA <br /> EPA T USE ONLY <br /> Application Accepted by Dais U �v � Area <br /> Pit or Grout Inspection by Date Final Inspection by Dete <br /> Additional Comments v �� <br /> scant - Return all copies to. flan Joaquin County Public Health <br /> Services, Eavl.roamental Health Permit/Services <br /> 1601 E. Raselton Ave., P 0 Box 2009, Stockton. CA 95201 <br /> FEE —AMOUNT DUE AMOUNT REMITTED CSC <br /> INFO CASH NECEIVER BY DATE PERMIT Ako— <br /> ciM 477 BEV iir3i ~`—"� �p <br /> t„ 4 b 07 zy �s-6-f U 41y-Zig <br />