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" R <br /> } APPLICATION FOR PERMIT <br /> fi+ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNTAL HEALTH DIVISION <br /> 1601 E. HAZELTON`AVE. , PHONE (209)468-3420 1 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> o <br /> PERI-IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) <br /> 1 <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. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Serviices. <br /> i � <br /> Job Address _!A61f - Sn 1S aaey J`j.[Y Citsa � sot Size/Acreage <br /> Owner's Name ID W- e- Address tL7 C7 S• �r/.1-dJz✓ Phone <br /> r l 6r <br /> Contractor "an S Address I7 2. 7 , License two. ?-3J 7.3 Phone z <br /> TYPE OF WELL/PUMP:. NEW WELL '4O❑ WELL REPLACEMENT� 0 1`�iDESTRUCTION ❑ Out of Service Well ❑ <br /> OTHER-❑- �._Monitor <br /> �,.Pt1MP INSTALLATION-I - SYSTEM-REPAIR-61 ��----�----- s,ngWell L3. .� <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION + AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom p Manteca Dia. of Wail Excavation Dia. of Well Casing <br /> fk-61,mestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'I Public 1-7 Other } 11 Delta Depth of Grout Seal Type of Grout <br /> 1 I Irrigation �..Approx. Depth Ii Eastern Surface Seal Installed by <br /> Repair.Work Done Lt"'Type of Pump X316 H.P. .__ 3 State Work Done <br /> Weil'Destruction'I ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 'I REPAIR/ADDITION I I DESTRUCTION I I tNo septic system permitted it public sewer is 0 <br /> available within 200 feet.) <br /> fnstallation�will (serve: Residence_ " Commercial_ Other ` <br /> Number of icing units: Number rof bedrooms 3 <br /> Character of'`soil to a depth of 3 feet: t Water table depth f <br /> SEPTIC TANK dh ❑ Type/Mfg a Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> LEACHING LINE ' Ll No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: rWell Foundation Property Line <br /> � �. <br /> SEEPAGE_PITS� ""1 I"'depth `f"}"- Size Number <br /> SUMPS �.. LI Distance to nearest:;yf»Well Foundation- Property Line <br /> --J OISPO.SA'L PONDS ❑ <br /> pplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> E hereby-certify that I have prepared this a <br /> rules and regulations of the San Joaquin County -r <br /> Home owner or lic a is signature certifies tt#`e,following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any per in such ma ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f owing: "I certif that in the perfo nc of work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws Califor a." , <br /> The app)' ani mu ca r al wired plated wing on r side. ti . <br /> Signed Title: �r1 Date: r2z Q <br /> .i <br /> r <br /> VEPAATMENTUSE-ONLY' <br /> Application Accepted by 1h, DateArea <br /> { <br /> Pit or Grout Inspection by } [ DateFinal Inspection by�- Data <br /> , <br /> Additional Comments: <br /> Applicant - Return s11 copies to-an Jos:quin County Public Health <br /> Services, Envirotvnental Health Permit/Services <br /> 1601 E: Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 <br /> f <br /> _'INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATE PERMIT'NO. <br /> + EH13-24(AE r✓� <br /> EH t4-2e o0 <br /> Y <br />