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_ 1 <br /> 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 BOX 2009, STOCKTON, CA 95201 f <br /> ii <br /> k EXP RES 1 YEAR FROM DATE ISgUIM <br /> (Coplete in Triplicate) <br /> Application is hereby made,to San1iJoaquin County or a permit to construct and/or install the Work herein described. This <br /> application is made 1n 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 <br /> �i9 City Lot Size/Acreage <br /> 29 <br /> Owner's Name Ane 4aeewKI Address ✓ - Phone + <br /> ' �A�P Usli License No._.�'S�Z `7 aZ 7d7 <br /> Contractor L.s . + Address Asa}- Phone <br /> TYPE OF WELL/PUMP: _.., .._NEW,WELL,D t SWELL REPLACEMENT DESTRUCTIpN,❑ Out-YoP Service well Cl. <br /> SYSTEM REPAIR ❑ . OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION D !!! <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 <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 3 Specifications <br /> {'1 Public <br /> L1 Other n Delta Depth of Grout Seal f ; Type of Grout <br /> IIIV ' <br /> I I Irrigation —,Approx. Depth l I Eastern Surface Seal Installed by t <br /> Repair Work Done 0 Type Of Pump 1IH.P. State Work,Done <br /> 0 Sealing Material & Depth <br /> Well Destruction ❑ Weil Diameter i <br /> Depth Filler Material & Depth <br /> \ r 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION 1 1 INo septic system.parmitted if public sewer is <br /> �available within 200 1eet.1 I <br /> Installation will serve: Residencej{ --. <br /> Commercial Other <br /> Number of living units: Number of bedrooms .3 - t <br /> Character of soil to a depth of 3 feet: II Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ #k Method of Disposal <br /> Distance to nearest: i Welk Foundation Property Line <br /> LEACHING LINE No. & Length of tinesry A. 4-t/� Total length/size <br /> I __ 1 <br /> FILTER BED ❑ Distance to nearest: Well -3Sc�� Foundation. wr - -.- Property Line �® <br /> SEEPAGE PITS J Depth 1 -- _Size Number <br /> SUMPS LI Distance to nearest: Weil r Foundation I� Property Line <br /> f / �i <br /> DISPOSAL PONDS ❑ r M <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, an <br /> rules and regulations of the San Joaquin County r, �` <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 toworkman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> i cenifies 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 /> I tion laws of California.,, <br /> k The applican must call for aH r wired inspections. Comp!Ita drawing on reverse side. <br /> 1 Signed X I /Title: j Date: 9a <br /> FOR DEPARTMENT U_ $E Q.NLY <br /> lr T _. 7 Z 0 <br /> Application Accepted by Date��^ ` ~ Area <br /> Pit or Grout Inspection by Die Final lnspection_by: - A,,V Date <br /> Additional Comments: '' <br /> l <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazeiton Ave., P Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED RECEIVED By DATE PERMIT NO, <br /> INFO CA5H <br /> . EH 13-24(REV.I/K5) 1-7 00� <br /> ? EH I425 <br />