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APPLICATION FOR PERMIT <br /> i SAN .IOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)4+6$-5420 <br /> P 0 BOX 2000, STOCKTON, CA 95201 <br /> PEUIT EXPIRES I `TEAR FROM DATE ISSUSt�^ » <br /> (Complete in Triplicate) *, <br /> Ayplicatica is hereby made•to San Joaquin County for a perzait to construct and/oriinstall ttte•vork herein described. his <br /> application is made in eoopliance vith San Joaquin County Ordinance NO. 549 and 1662 and the Rules and lkagulstiohs of,San <br /> Joaquin County Public Health Services. t <br /> Job Address _ ►`t" City Lot 81%e/Acreage <br /> 1 <br /> F <br /> 's Name Addressr ,a Phone <br /> Owner � G�,t�.�f. ,�+N-i-��"_.. ...:..'""�._ ..... .... - - - _ .. .. <br /> � <br /> Cont+actor f Address 2 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL C) WELL REPLACEMENT^C.i DESTRUCTION Ua Out Of Service Well C <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O D{onitaring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial n 0 Open. Bottom 0 Manteca Dia. of Well Excavation-� Dia. of Well Casing <br /> ("3 DamesticlPrivtate + 0 Gravel Pack El Tracy Type of Casing � Specifications <br /> Fl Pubic 'I Other 11 Delta Depth of Grout Seat Type of Grout <br /> I I irrigation r —.Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Crane 0 Type of Pump H.P. State Work Done <br /> Well Destruction Cl Wall Diameter Sealing lHaterial 6 Depth <br /> Depth A i filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION REPAIRiADDITION 1 I DESTRUCTION i I .lNo septic system permitted if public sewer is <br /> r available,within 2W lest.) <br /> Installation wilt"ierve.T-Residents Commercial_— Other ' S +- <br /> 1 N` <br /> Number of living units: ` Number of bedrooms _ <br /> Character of soft to a depth of 3 feet: t.!kagev �e?]C�V� Water table depth <br /> SEPTIC TANK. f='-�Capacity ( lb n No. Compartments <br /> PKG. TREATMENT PLT.C(7 \ f , Method of p'ns osat <br /> � <br /> j Distance to nearest: Well Foundation i jj�) - Property Line_s ...--.-...» <br /> LEACHING LINE `1, No. 6 Length of lines _Total [length/size <br /> FILTER.BED i CJ �Distance to nearest: WaN l;r3'1— Foundation Property Line <br /> ✓<; <br /> SEEPAGE PITS t'I 'Depth `_ Sire _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina-L <br /> DISPOSAL PONDS I:7 <br /> I hereby comity 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 of licensed ageru's signature cartifieb 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 ars to become subject to workman's compensation taws of California."Contractofs hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issusd,J.stwli employ peraons subject to workman's compensa- <br /> tion laws of California." I t <br /> The applicant must calof all req �iinspections. Complete drawing onfrjeverse side. <br /> Signed X � , ,t l.I,� .r .� Title. " r`��{tnlfs' Date: !'I <br /> C FOR DEPARTMENT USkPNLYi r/rr r� <br /> Application Accepted by' '` a Date "' �1) I Area <br /> r y'P� �!t <br /> Pit or Grout Inspection by Data Final inspection by Data <br /> Additional Comments; <br /> Ayplicaat - Return all copier to: San Joaquin County Public Health <br /> Services, IItviroamental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> EEE AMOUNT DUE AMOUNT REMITTED CK,J RECEIVER 9Y a DATE PERMIT NO. <br /> INFO CASH <br /> EH tYM tr1EV.�/net. S -1 d'-'l 6•- 1 q,� <br />