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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> II' ENVIRONNTWAL HEALTH DIVISION <br /> 13.601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> I P O BOX 2009, STOCKTON, CA 95201. <br /> PEMIT EXPIRES X YEAR FRQM DATE ISSUED <br /> i (Complete in Triplicate) <br /> L <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _Lg�O 11J .;&A2-- A-1 - City; 77; A l Lot Size/Acreage <br /> Owner's Name -572=5P.eL4) Address .27P4 PA­'jGirr Phone <br /> s <br /> Contractor ELO-11D 4, Lola"od Address 7 .4/, License No. /z/ Phone `ref '77/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weli ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC•TANK- WER-LINES--- -- - - DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AG ICULTURE WE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A A STRUCTION SPECIFICATIONS <br /> 111 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Typa of Casing l Specifications <br /> !'1 Public C] Other r fl D a epth of Grout Seal Type of Grout <br /> I I Irrigation �.Approx. Depth Eastern S ace Seal Installed by <br /> r <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Maters & Depth <br /> Depth Filler Material & pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 4K DESTRUCTION I I (No septic system permitted if ptiblic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial,.._. Other <br /> Number of living units: —/—_ Number of bedroom_ s <br /> # Character of soil to a depth of 3 feet: L Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg - - Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE Lel No. & Length of lines Total length/size <br /> 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> z <br /> SEEPAGE PITS 1 I Depth Z 12 Size' -1 1 b -_- Number — <br /> SUMPS X Distance to nearest: Well _ Foundation Z<- Property Line -S1 <br /> DISPOSAL PONDS 0 tP 11 LV A 77ZEL2 <br /> I hereby certify that I have prepared this application acid 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 S <br /> Home owner or licensed agent's signature certifies the following: 1 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 /> M 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." 1 . , <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: A-1 <br /> Date: I <br /> ODEPARTMENT EPARTENT USE ONLY <br /> - T E Z_�z I <br /> Application Accepted by Dare Area _ <br /> Pit or Grout Inspection by Date Final Inspection by Date_�a <br /> I <br /> I, Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> , <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> r INFO AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N071 <br /> . EH 13-24(REV.i i n 51 <br /> EH -zs <br /> t <br />