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APPLICATION FOR PERMIT <br /> i <br /> " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICPS 7 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br />' <br /> EXPIRES 1 YEAR FROM DA ED I/�°NNiFtiT g X990 <br /> (Complete in Triplicate} �� <br /> Application is hereby made to San Joaquin County fora yt4'' <br /> application Is made in comtpliance with San Joaquin countyrordinancenNo. 549sando1862stall and thee work Rules andein Regulationadof Sans <br /> Joaquin County Public Health Services. <br /> i <br />' Jab Address 3 0 4 ,� -RD L �� � <br /> QM \ p City '� Lot Size/Acereeage _ SC-. <br /> Owner's Name R t�� Address i c� a�[-9/�•/y � ) <br /> Phone <br /> M�T LL ,�rte1 <br /> Contractor Address i.� /r A) <br /> License No.&6!!w Phone 4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well-0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OITHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �i 1 <br /> {7 Industrial Cl Open Bottom l <br /> P IT Dia, of Weil Excavation Dia. of Well Casing <br /> C7 <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'I Public i <br /> Cl Other f-1 Delta Depth of Grout Seal <br /> I I Irti ation Type of Grout. <br /> 0' ­Approx. Depth i I Eastern Surface Seal Installed by �� �s <br /> Repair Work Done L7 Type of PumpH.P. State Work Done Tt <br /> Well pest►uction ❑ Well Diameter Sealing Material Depth h, <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION i I (No septic system permitted if public sewer is <br /> AOL.D)f46r -TANK LNQ of /l available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number o edroo s <br /> Character of soil to a depth of 3 feet: > <br /> SEPTIC TANKWater table depth AS <br /> ❑ Type/Mfg J ity—�Zy No. Colmpartments 19V <br /> H[7 Di TREATMENT PLT. ❑ �Q L Cv,ac¢�[ Pc+vUCIS <br /> N6r ANIS D'stan to near 1: W I! 2 F undation Z Oft Method of Disposal <br /> Ploperty Line I.._.�Q ��QH <br /> LEACHING LINE ❑ No. & Length of lines <br /> P/ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> - Property Line1 <br /> SEEPAGE PITS �Ll <br /> 1 Depth Sire 11 <br /> SUMPS — Number <br /> Distance to nearest: Well Foundation Property LineDISPOSAL PON S <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'Iwhich 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 folio ing: " r that in the performance of the work for which this permit is issued shall employ tion laws C ornia " P y pe sons subject to workman's compensa- <br /> The appl' mus <br /> c requir insPections. Complete drawing on verse sid s ,r <br /> Signed J' <br /> Title e✓ V �S� <br /> ate: <br /> OR DEPARTMENT USE ONLY !'t <br /> Application A copied by ,, S•- <br /> Date3 ", -- qp <br /> _ Area <br /> Pi of Grout Inspection b Date %' /J�j i <br /> Final !ns *ctio`by"lr�fd Date <br /> n �� —T i <br /> Additional Comments: Leh � J�}� i � ,�(-�" � I <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> i <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95202 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED HY <br /> (( CASHH DATE, PERM17'NO. <br /> . EN 13-24(REV.rtN5) -70.0D '-10.0o 1 I1.3� <br /> EN 14.26 <br />- G-s- 10 90_ 3�Ji <br />