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4 APPLICATT FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 -E.`' HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES;�-YEAR FROM DATE ISSUED <br /> (Complete. in Triplicate) <br /> r Application is hereby made to San Joaquin County fora rmit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. // d / <br />{ Job Address .�5. !�/ /�/-U C C � City GOoa Lot'Size/Acreage 23 <br /> f <br /> Owner's Name 3 37 y Q 3 <br /> Address Phone <br /> Contractor `-Address 'J - 'License No.s 7;> Phone 33 `12 <br /> F TYPE OF WELL/PUMP: NEW WELL©., ' WELL REPLACEMENT DESTRUCTION Out of Service Well - 0 <br /> PUMP INSTALLATION '�' '' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK lr12-_t SEWER LINES 'IDISPOSAL FLD./S2 PROP. LINE �0 <br /> FOUNDATION �AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED U__SE : TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca y`Dia:of 1W411 Excavation lZ Dia. of Well Casing <br /> ` 'Domestic/Private ❑ Tracy Type of Casing � ^TSpecifications.Gravel Pack y� a <br /> a-. <br /> �* i'I Public Cl Other n Delta Depth of Grout Seal 1c�[�7 Type of Grout Co— `.- <br /> I I Irrigation S/J Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump State Work Done <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter'"lj t' n8 .+ llVt <br /> *1e Depth_ . ,k I,Filler Material ;>< Depth <br /> nu4 wz <br /> TYPE OF SEPTIC WORX: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is . <br /> t - ' r available within 200 feet.) <br /> r Installation will serve: -Residence_. Commercial._-_O.ther r <br /> Number of living units: 'Number of bedrooms J <br /> Character of soil to a depth of 3 feet: Water table depth <br />{ SEPTIC TANK. <br /> 0 Type/Mfg Capacity No. Compartments <br /> I <br /> PK G.,TSEATMENT PLT, ❑ a• Method of Disposal <br /> Distance,to nearest:;----Well---v-� Foundation Property Line <br /> I LEACHING LINE ❑ No. & Length of lines s Total length/size ` <br /> i FILTER BED n Distance to nearest: Well Foundation , Property Line �. <br /> SEEPAGE PITS I ! Depth Size Number <br /> SUMPS -----L-I. Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS- .- ❑ <br /> _ 1 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 tali for all required inspections. Complete drawing on reverse side. <br /> f� Signed Title: .._ — Date: <br /> S) <br /> F. DEPARTMENT USE ONLY <br /> Application Accepted by Date ZAI <br /> Area <br /> Pit or rou Inspection by � / Date ._ Final Inspection by Date <br /> Additional Comments: r _ �q• 6 <br /> Applicant - Return all copies 13an J6,quin County Public Health <br /> k a Services. Environmental Health Permit/Services - u -• <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> CK 4 <br /> ~ ;. INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �, DATE PERMIT'NO. <br /> 1 + EH 13.24 IREV.+y x 5s <br /> EH 11.2e Z <br /> P IV g5--00 qlr par 1.3 c(,ev •j <br />