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APPLICATION FOR PERMI <br /> x <br /> may" r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , HONE (209)468-3420 L <br /> P O BOR 2009, STOC TON, CA 95201 <br /> ZEMIT EXPIRES 1 YEAR FROM DATE_ ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application to made in compliance with San Joaquin County Ordinamcc No. 5h9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. P <br /> `M k/ doll�S4lJob Address A dress <br /> City Lot Size/Acreage <br /> Owner's Name L 0t4n ersoll� Cla/fi.(4w <br /> -- <br /> Phone <br /> Contractor G I1�° , ess y �i J [ / 7License No. //9 Phone 7 <br /> TYPE OF WELL/PUMP: NEW WELL tt! $ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well (1 <br /> PUMP INSTALLATION ? SYSTfy1 E AIR C7 OTHER ❑ MonitoringWell <br /> DISTANCE TO NEAREST: SEPTIC TANKy SEWER LINES /Y DISPOSAL FLD. PROP. LIVE ZE) <br /> FOUNDATION jt` AGRICULTURE WEL OTHER WELL PETS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU TION SPECIFICATIONS <br /> ie— <br /> r <br /> (3 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (I DomesticlPriva e K Gravel Pack W Tracy Type of Casing— Specifications ., f <br /> W Public 1'J60rfti%r (1 Other i 1 pelta Depth of Gr ut Seal 3 <br /> P Type of Gtout. C1« <br /> I I Itrigation _Approx. Depth I I Eastern Surface Soul installed by <br /> Repair Work Done (.J Type of Pump H.P, PIto W rk D e <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material b Depth J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 (eet.I <br /> Installation will serve: Residence_ Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of Boll to a depth of 3 feet. _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Gap city No. Compartments <br /> PKG. TREATMENT PLT. M Method of Disposal _ <br /> Distance to nearest: Well Foundatio — Property Line <br /> � l <br /> LEACHING LINE Ll No. & Length of lines _ Total length/size , <br /> FiLTER BED 1:1 Distance to nearest: Well Foundation _ Property Line i <br /> SEEPAGE PITS 11 Depth Size _ Number _ <br /> SUMPS Ll Distance to nearest: Well Foundation_ _ Property Line _ I <br /> DISPOSAL PONDS O <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 canifies the following: "I certify that in thq 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 compensatiom 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 cornpensa. <br /> lion laws of California." <br /> The applicant must II fo,all required inspections. Complete drawing on reverse side. / <br /> Signed X Title: 0(�' �fl�Zt Date: I�'ind .�/ 1�I <br /> FOR DEPAR MENT USE ONLY <br /> Application Accepted by Date �+�'► l3 yU Ares ._ Y 5�.____ _ <br /> PitGrout spection by DateFinal nspection by <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Fe t/Services <br /> 1601 E. Hatelten Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT RENtITTEO CASHRECEIVED By GATE PERMiT'NO. <br /> • trr 321 Ir1EV. Ivo <br /> 3 3s .ov <br /> 13i�3s 13 <br />