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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FR M AT <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 glade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. W <br /> p p E <br /> Job Address __ -(Ob0 6_ -_� lw,( t f� City �7 G Lot Size/Acreage <br /> Owner's Name .1�Td500 ei ddress Phone <br /> i <br /> Contractor_rel.�. Y��1-C Q Address _"_2C5, /Y`, �-47e_1,4 License No,�_,k6� -Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.'of Well Casing F <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public C.1 Other n Delta Depth of Grout Seal Typo of Grout i <br /> i I Irrigation —�- =.Approxi Depth's I l"Eastern-J" Surface"Seul'lns�alled by '� " "'" ! <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction 0-'Well Diameter Sealing Material & Depth � <br /> Depth Filler !Material & Depth <br /> TYPE OF SEPTIC WORK;`NEW INSTALLATION REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted if pub:hc sewer is <br /> available within 200 feet.l <br /> -Installation wiflsenre: Residence <br /> �Commerciaf T, Other _ p <br /> Number of living units: 4-_ �Number of bedrooms <br /> C i <br /> Character of soil to a depth of 31feel:--- . A(L3 �. . Water table depth <br /> SEPTIC TANK; 0 Type/Mfg ry Capacity_ 7�10. Compartments + <br /> PKG. TREATMENT PLT. Cl Method of Disposal t ' <br /> Distance to nearest: Well tC_-- Foundationf'ro ert l iae. <br /> t I ---. p Y <br /> 1 <br /> LEACHING LINE tg No. & Length of lines t � ✓. .Total length/size 0 <br /> F" <br /> FILTER BED ❑ Distance to nearest: Well��Foundation_o?/a ' Property Line. ,71� _­-7— <br /> SEEPAGE PITS 11 Depth /� f T Size. x!1 Number <br /> SUMPS i 6A Distance to nearest: Well//0JFjr7_Foundation Property Line t <br /> DISPOSAL PONDS ❑ �. <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 .. t <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, f shalt 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 pbrsons subject-to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for at quire inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> G <br /> Application Accepted by Date 22 �d Area <br /> Pit or Grout Inspection by Date Final Inspection by ate27 �lrJ <br /> a <br /> Additional Comments: <br /> Applicant - .Return all. copies to: San Joaquin County Public Health <br /> Services, mvironmental'Health Permit/Services <br /> .1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEF INFO- AMOUNT, ___ __AMOUNT-RENtITTEdµ_ CK f C'ASH""" RECEIVED BY --DATE-,.--,, _PERMI7'NO:_ <br /> + EH 13-241r1EV.i/a+ss <br /> EH 14•26 !!! 7 <br /> r <br />