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f. <br /> 1 <br /> I APPLICATION FOR PERMIT ` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION A/0 <br /> 0 <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE 1PUED / <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 <br /> trwith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Ser vices. Y /} <br /> Job Address �L/f� Q �_� City Lot Size/Acreage SD X/60 <br /> Owner's Name AddressAZIS WC-021 8 <br /> Phone <br />- <br /> 77&_1 <br /> Contfactar , Address License No. f` Ph�Se <br /> TYPE OF WELL/PUMP: NE ELL.C1, WELL R PLACEMENT ❑ DESTRUCTION ❑ Out oce We11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST, SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 1 -FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL '-PRQBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial 0 Open Bottom ?m 0-Manteca Dia. of Well Excavation Dia. of Well Casing <br /> M Domestic/Private ❑ Gravel Pack I E7 Tracy Type of Casingi i <br /> Spec f cations <br /> Cl Public f7 Other Cl Delta Depth of Grout Seal Type of Grout <br /> - <br /> I I Irrigation �,-Approxi Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction 0 Well Diameters Sealing Material & Depth 4 <br /> Depth i Filler Material & Depth N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> I available within 200 feet.! <br /> Installation will serve: Residence'1 Commercial '­'­Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line s <br /> LEACHING LINE ❑ No. & Len 'h of lines <br /> g Total length/size s <br /> FILTER BED Cl Distance tolnearest: Well Foundation Property Line ` <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to?nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L] +� <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 i <br /> 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, !shall employ persons subject to workman's compensa- <br /> tion laws of California." t <br /> The applicant must c II for all require pections. Complete drawing on reverse side. <br /> � ' t <br /> Signed I Title: Date: <br /> E ONLY <br /> Application Accepted by A t Date Area <br /> i <br /> Pit or Grout inspection by � Data - Final Inspection by bate y ' <br /> Additional Comments: <br /> Applicant Return all copies to: Isan Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 2. Hazelton Ave.. P O Box 2009, Stockton, CA 95201 <br /> FEE DONT Durr AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EM I3-24(REV.iiHSi l" <br /> EH 14.26 �., c0 <br /> �S �b <br /> M <br />