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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC 1EALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION / . <br /> f� <br /> 1601 E. HAZELTON AVE, , PHONE (209)488-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PF MIT EXPIRES 1 YEAR FROM-DATE ISS Ep <br /> (Complete in Triplicate) <br /> Application is hereby me,de"to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in covillil.iance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aiid-Reguli tions of San' <br /> Joaquin County Publ1c Health Services. <br /> Jab Address Y,� !ter L-�)l.�l / � itC R City Lot Size/Acreage!. `d/Tr rte/ <br /> Owner's Name r+ "' exk�,L_, Address Al- (A5t Zkff Phon �L `l7,24" <br /> Contractor q,9_fi)5._ gc/YP T Address _ 8� License No.� _Phone <br /> TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEM NT Cl DESTRUCTION O Out of Service Well""D <br /> PUMP INSTALLATION ! SYSTEM REPAIR ❑ OTHER O Monitoring Well (1 <br /> DISTANCE TO NEAREST: SEPTIC TANK>/000/ SEWER LINES ?!f/A0' _ DISPOSAL FLD�_ PROP. LINE <br /> FOUNDATION­'_'&21 � AGRICULTURE WELL OTHER WELL? j/)` PITS/SUMPS>J_C00/ <br /> �.. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Y fl <br /> Cl Industrial Open Bottom Cl Manteca Dia. of Well Excavation_ " Dia. of Well Cas' g <br /> C) Domestic/Privett---_ El Gravel Pack O Tracy Type of Casing L- jz.; •( Specificatiopa <br /> I'I Public 0 other / _ n Delta Depth of Grout Seal Type of Grou <br /> Irrigation ���Approx. Dept I I/Eastern Surface ?9� <br /> -, Seal Installed by l � �y <br /> Repair Work Done C3 :Type of Pump �� G��"- H.P. 49,faState Work Done <br /> Well Destruction O" Well Diamet _ gosling Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I tNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units:" Number of bedrooms <br /> Character of soil to ra depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> r <br /> PKG. TREATMENT PLT. O" , Method of Disposal <br /> iDistance to nearest: Well foundation Property Line <br /> LEACHING LINE O No. & Length of lines _ Total length/size— <br /> FILTER <br /> ength/sizeFILTER BED 1 D Distance to nearest: Well Foundation ` Property Line n <br /> SEEPAGE PITS .i 11 Depth —_—Size Number — <br /> SUMPS } CI Distance to nearest:- Well _ Foundation___ Property Line <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 certifies 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,I shall employ persons subject to workman's cornponsa- <br /> tion laws of Calif 'a," <br /> The applica t call for al rogl inspec ons, Complete drawing on re o side, <br /> Signed K Title: _-----___-- Date: �� <br /> t <br /> ` F" D £,ARTMENT USE ONLY <br /> 4 Application Accepted by _- (b.o _ Date_ -� ` _ Area { _ <br /> I` r� <br /> Pit or Gro t Inspection by r-. .��-�Datej '�G q� Final Inspection by_ .rAZ-. para <br /> i Additional Comments: <br /> Applicant — Return all copies to. Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> f 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CK' <br /> INFO AMOUNT OUE AMOUNT REM CASHRECEIVED BY DATE PERMIT"NO. <br /> . ` - <br /> EH 13-24 IREV. 7V /34/.L'10 <br /> 3�O �L/ .� <br /> EH a.X Y 19� <br /> L l <br />