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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-'3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> E%PIRES 1 YEAR FROM DA ED <br /> (Complete in Triplicate) <br /> Application is hereby ma,de,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 862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. t <br /> Z T l� � Lot Size/Acreage f <br /> Y Job Address City <br /> / <br /> s � ' Phone 73/- 0 <br /> Owner's Name Address { <br /> Per L4 ��s S License No. 1_3y� <br /> ,(Contractor <br /> Al �' I' rens - <br /> TYPE OF WELL/PUMP: NEW LL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service-W-110 <br /> MP INSTALLATION D Moni ring Well <br /> SYSTEM REPAIR C7 OTHER O <br /> DISTANCE TO NEAREST: SEPTI SEWER LINES DISPOSAL FLD. P- LINE <br /> � PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCT CIFICATiONS <br /> I E Industrial <br /> C1 Open Bottom 0 Manteca all Excavation <br /> Dia. of Weil Casing <br /> Type of Casa Specificat of ns <br /> (.I Domestic/Private Ll Gravel Pack L7 Trac Type of Gr6ut t <br /> t'l Public CI Other elta Depth of Grout Seal _ <br /> 1 I Irrigation —App • epth I I Eastern" ^'"Surface Sea!Tr1s a e k <br /> State Work Done <br /> Repair Work Done U of Pump H.P. <br /> Sealing Materiai &,Depth <br /> Well Destruc n { Well Diameter C ri f <br /> Depth -------^ ! <br /> I <br /> Filler Material _ pth� - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 17 DESTRUCTION i I (No septiclable thin stem <br /> permitted if public sewer is <br /> avaE <br /> Installation will sive: Residence— [:ommerciaf - char•----- •--- , <br /> a. _ <br /> t, <br /> Number of livingtunits: Number of bedrooms A vi A r .- 1 <br /> Character of soil to a depth of 3 feet: ! Water table depth <br /> =`4 ,J �1 6 C - - No. Compartments <br /> SEPTIC TANK �� ypelMfg Capacity _ <br /> PKG. TREATME T PL cc `t Method of Dispose <br /> Distance to nearest: Well •. V Foundation Property Line <br /> LEACHING LINE No. & Length of lines a ��' 1 �F'Total�length/size_ <br /> FILTER SED 0 Distance to nearest: W41* it- <br /> {, Foundation 3 Property Line <br /> k SEEPAGE PITS Depth Size `�+ Number — <br /> is 1 <br /> SUMPS L1 Distance to nearest: WeII,, a Fa ndation ° t�' Property Line }}' <br /> f DISPOSAL PONDS Cl <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 which this permit is issued, I shall not <br /> f 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 parmit is issued, (shall ampto rsons subject to workman' compensa <br /> r tion laws of California." I <br /> Thead X pplica mustcallr alt req ired inspections. Complete drawing on reverse side. /� <br /> Signe ��— <br /> r Title: Date:. <br /> T-USE-ONLY <br /> w � •.r' +�`'��___.�— <br /> Area <br /> F Application Accepted by Data <br /> ri <br /> lorGrout Inspection by Date Final Inspection by Date( -1 € <br /> l Additional Comments: <br /> 4 ! <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services + <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> _Z-FEE- ""AMOGN7'REfNIT TEI7 " " —RECEIVED"BYE �� �ATfc PERMIT NCASHEH 13-241AEV.I/KSI 1�� <br /> EH 14.26 <br />