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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby m►ade,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 /> i <br /> Job Address r � City — __ Lot Size/Acreage <br /> f�r�7b l7��r' .r _ Address 'E� Jt Phone' s <br /> Owner's Name P <br /> �JJ � � ti �1I <br /> ContraCl0 L��,a5 _AddressT�i�f c J[jnc � ,__ License N Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Weil ❑ <br /> PUMP INSTALLATION ET' SYSTEM REPAIR C7 OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Q,Lt <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S <br /> R industrial- Open Bottom- ❑-MantecaDia. of Well.Excavation._ - Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack D Tracy Y Type of Casing Specifications <br /> lic :1 Other t 1 Delta Depth of Grout Seal"�St� Type of Grout <br /> 0*1", <br /> ation Approx. Depth ll,I Eastern Surface Seal Installed br Work Done U Type of Pump �_dd h H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> 'Depth Filler Material & Depth f�r� <br /> Y OF SEPTIC WORK: NEW INSTALLATION I I REPAIR1ADOfTION I I DESTRUCTION I I INo septic system permitted if public sewer is I `w <br /> available within 200 feet. <br /> Installation will serve: idence _ Commercial ,.___.. Other I <br />•- Number of living units: _ er of bedrooms <br /> _ Character of soil to a depth of 3 feet: ater table depth ! <br /> SEPTIC TANK. CI Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, CI Method of Disposal <br /> Distance to nearest: Well dation Property Line <br /> LEACHING LINE CI No. & Length o s 1 length/size <br /> FILTER BED 1.3 Dista nearest: Well Foundation rty Line ' <br /> SEEPAGEPITS I 1 Depth Size Number <br /> SUMPS l I Distance to nearest: Well Foundation Property Line <br /> DJSP6SAL PONDS 0 <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 fegulations 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 compensa- <br /> tion laws of California." t <br /> The applicant must pall for all requir d inspections. Complete drawing on revels side. <br /> i <br /> Signed - Title: _ Date: <br /> FRJR DEPARTMENT USE ONLY /h <br /> Application Accepted by _ Date rr. �_ Area <br /> Pit orro t Inspection by a--late/2 Final Inspection by r <br /> 1 <br /> Additional Comments: r <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 952011 ' <br /> 1NYF6/ AMOUNT DUE. . .... AMOUNT,REWTTED CASH RECEIVED BY .DATE PERMIT'NO. <br /> + Err 13.241 REV.1)851 `~ 1J L�� / r? ' *:.1 /j�c/_9/ W_ <br /> _� 8 <br /> EH 14.2E ( L cJ ! O <br />