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A <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DAIE ISSUED <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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / <br /> Job Address LFALE - y` ,. City Lot Size/Acreage <br /> I <br /> Owiier's Name"LLV Address � �� Phone <br /> a <br /> .-CWtiacl !' Addses License No Phon <br /> "- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK-_ f Y,__ SEWER LINES e' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIPICATI DNS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing <br /> 1 Domestic/Private .T U Gravel-Pack - ." C] Tracy- -- -Type-of-Gasing - — - Specifications <br /> I'I Public Cl Other 171 Delta Depth of Grout Seal Type of Grout <br /> I'I Irrigation —.Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done E3 Type of Pump H.P. State Work Done <br /> We llDestruction ❑ Well Diameter Sealing Material &:iDepth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> f available within 200 feet.I <br /> Installation will serve: Residence-%., 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 -Nci.-Compartments <br /> MG. TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: ! .Welles Foundation " " ' Property Line <br /> LEACHING LINE No. & Length of lines., Total length/size <br /> FILTER BED 0 Distance to nearest: WeII5— Foundation T 7 Property Line <br /> SEEPAGE PITSDepth =Sire Num or <br /> IV or i <br /> SUMPS Ll Distance to nearest: f Well, -Foundation Property Line oi!�e ._ <br /> DISPOSAL PONDS CIL <br /> { F <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 certifyedhet 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." ' <br /> The applic m st. all, or-ail r quired inspecti Complete drawing on reverse side. <br /> Signed t Title: <br /> -USE ONLY <br /> Application Accepted by 4. Date Area <br /> Pit or Grout Inspection by Date a Final Inspection by �' C Date <br /> t <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Cou4ty Public Health <br /> -- - - ---- - •- -- 5ervices;~Envirotsmental`Hi;al`th Permit/Servi`ces <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 / <br /> IFERZO N AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'N0. <br /> + EH132i IAEV.i/n 5V _ O �� V <br /> EH 11 . V VVV ! <br />