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d. 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 0 BOX 2009, STOCKTON, CA 95201 <br /> ' ED <br /> EXP RES 1 YEAR FR M DAT <br /> I (Complete in Triplicate) <br /> the work <br /> Application is hereby made,to San Joaquin County <br /> for a permit to construct anndo1862saand aherein described. <br /> the andRegulationsof Sans <br /> application is made in compliance with San Joaquin County Ordinance No. 549 <br /> Joaquin County Public Health Services. Lot Size/Acreage <br /> rn l�()4N City ..7 <br /> Job Address Phone <br /> �Q lis Address t� <br /> Owner's Name "-S IS /7 <br /> , [c IRC) f`K r� License No. �I Phone <br /> Contractor IaGI w Address-'-a DESTRUCTION ❑ Out of Service well ❑ <br /> NEW WELL ❑ WELL REPLACEMENT C� OTHER ❑ Monitoring well L7 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION DISPOSAL FLD._ PRO?. LINE <br /> SEWER LINES �----�-- <br /> DISTANCE TO NEAREST: SEPTIC TANK -�- AGRICULTURE WELL �— OTHER WELL��-- <br /> PITS/SUMPS <br /> FOUNDATION --- <br /> TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia of Welt Casing <br /> INTENDED USE <br /> ❑ Open Bottom C3 Manteca Dia. of Well Excavation Specifications <br /> n Industrial 0 Tracy Type of Casing <br /> ❑ Gravel Pack Type of Grant <br /> Domestic/Private <br /> i'l Public I1 Other <br /> ❑ Delta Depth of Grout Seal <br /> i I Eastern <br /> Sure Seal installed by <br /> �. Approx. Depth <br /> State Work Done <br /> I 1 Irrigation H.P. �•.-_ !� �XrsTiq✓rj <br /> Repair Work Dans 0 Type of Pump Sealing <br /> Material & Depth <br /> Wetl Destruction ❑ Well Diameter �---- Filler Material 5 Depth �L ` <br /> III Depth <br /> TYPE OF SEPTIC WORK: NEW lNS7ALLATION I 1 REPAlR1ADDITION i ! DESTRUCTION I l availablelw Thin 200 feet.) <br /> 11 public sewer is <br /> I Installation will serve: Residence 4 Commercial — Other--- <br /> r 0 <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feel: Capacity -- No. Compsrtments <br /> F <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.❑ Foundation� Property Line <br /> Distance to nearest: Well <br /> k Total length/size <br /> 4 LEACHING LINE ❑ No. & Length of lines, Foundation Property Line_ <br /> FILTER BED ❑ Distance to nearest: Well <br /> ....._�..�- <br /> t• <br /> Number <br /> SEEPAGE PITS i I Depth f Size Foundation property Line <br /> SUMPS Cl Distance to nearest: Well� --- <br /> _���-- <br /> DISPOSAL PONDS ❑ } <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-af-the work•for which this permit is issued, k signature <br /> shall not <br /> employ any person in such manner itis comemance of the work foswh ch this permit is,iss edation laws of 'fpshall employ persons rnia." Contre9tor.'s lsubjecring t to wcarkman1s pompe sa- <br /> certifies the following: -I certify <br /> that intion laws of California." ' C(� <br /> The applicant.•must call for i!I required i� r tions. Co plate drawing on verse side. <br /> �/J-,` f Daljate: �� <br /> Title: <br /> Signed3_ <br /> MEN7 USE ONLY <br /> Date 'Area <br /> Application Accepted by ate <br /> Pit or Grout Inspection by <br /> Date -- Final Inspection by <br /> m Additional Comments: <br /> Applicant - Return all copies to: Servicesa1Environmental tblHealthtPermit/Services <br /> r <br /> f 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> f CK RECEIVED By DATE PERMIT N0. <br /> iFEE AMOUNT DUE 1,AMOUNT REMITTED CASH <br /> r EH 13.24IREV.1/MSI pa LAS] .© <br /> . EH 7t-26 <br />