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APPLICATION FOR PERMIT <br />` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> 1641 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> M P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT 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 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 ff:� Z gA21 eq= Zirj6Z f City C� Lot Size/Acreage <br /> Owner's Name ]c, Address Z D( &e j�7• Zamelr-_ -e_ Phone fr <br /> /"! ('7-�i r7 Flat �. s7 d dress y� �8.�1 _ (�39 <br /> Contractor tl � � l�-(3Q License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION Out of Service well -4A <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER E) Monitoring well t7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. L m PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial 0 Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing �+ <br /> t <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public [-1 Other Fl Delta +1 ' Depth of Grout Seal— Type of Grout <br /> . 1 i Irrigation w.,Approx. Oepth I I Eastern 'Surface Seal Installed-by <br /> ` Repair Work Done U Type of PumpH.P. <br /> " Welt Destruction 4L Well Diameter Sealing Materiel & Depth <br /> i Depth 3(� I Filler Material & Depth <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 feet.) f <br /> Installation will serve: Residence_ Commercial T Other w - VIP <br /> Number of living units: Number of bedrooms <br /> Chafacter of soil to a depth of 3 feet: Water table depth <br /> x SEPTIC TANK. El Type/Mfg ` Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines µ Total length/size <br /> FILTER BED ❑ Distance to nearest; Well ` Foundation Property Line y <br /> SEEPAGE PITS 1 ) Depth Size ! "` "'Nuritber <br /> SUMPS Ll Distance to nearest: Well Foundation '' �'�.t Pro <br /> party Line <br /> DISPOSAL PONDS 0 <br /> I hereby cenify 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 . t .. - _. . <br /> u. _ .;Home owner or licensed agent's signature cenifies the following: "I 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued,J shall employ persons subject to workman's compensa- <br /> tion laws of Californ u <br /> The applicanttrfi call for all required inspections. Cor9plyte drawing on Aeverse side. ,l} <br /> Signed "� 5 9�/' // I C..3 Z CD Date: <br /> FOR DEP MENT USE ONLY ?� <br /> Application Accepted by Date <br /> a <br /> Pit or Grout Inspection by Date Fin nspection Date <br /> i <br /> r <br /> Additional Comments: ; <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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> . EH 13-Z41RE11,fFnS� -��iq r`' <br />