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APPLICATION FOR .PERMIT noir a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZPLTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> Y Dtti'Rl IT EXPIRES 1 YEAR FROM rDATE JaVL , <br /> ;I (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 i <br /> application is made in compliancelvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> .� City Lot Size/Acreage <br /> Job Address /� <br /> � 1 Y r t, t�,�j _ Address �/`L f�~ Phone <br /> Owner's Name .mss.. ✓ 'J " ' - <br /> 7 I. �1 fN 1? _License No. 7�a S ^Phone '�? <br /> Contractor�� Address � - <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT El DESTRUCTION`C Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK �n- __ SEWER LINES l DISPOSAL FED. - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED'USE ---TYPE OF WELL�� PROBLEM AREACONSTRUCTION-SPECIFICATIONS.. - Dia. Well Casing �# <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat n �; Specifications <br /> Domestic/ Gravel Pack L7 Tracy Type of Casing I <br /> 11 ( - C1 Delta Depth of Grout Seal t O'D Type of Grout_ 4e 4k <br /> I'] Ptiblic I_l Other - , - c- <br /> Al t Gia <br /> I I lrrigation Lc7� Approx. Depth 4 I Eastern Surface Seal installed by � <br /> of Pump t I_fStaie Work Done L1,I.& -- <br /> F Repair Work Done U Type . --s�=-�,� "'"H-P' l th c <br /> ..-Sealing Material-B--Dep <br /> LZ <br /> Well Destruction ❑ Well Diameter _---� Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAtRIADDITION I I DESTRUCTION I I aNailabptiw thin system <br /> rented if public sewer is <br /> Installation will serve: Residence Commercial= Other co <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:F Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg <br /> Capacity's No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> f <br /> > Distance to nearest: Well Foundation �� 'Property Line <br /> wLEACHING LINE ❑ No. & Length of lines A_ " _ Total length/size' } <br /> EaLTER.BED ❑ Distancelto nearest: Well y Foundation- Property Line <br /> s•' I ` <br /> SEEPAGE PITS l 1 Depth k l Size Y j Number. ` <br /> SUMPS LI Distance io nearest'. <br /> Foundation Y Property Line . <br /> f <br /> DISP05AL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stela laws, and <br /> ate , rotes and regulations of the San Joaquin County <br /> Rify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <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: 111 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." F <br /> The applicant must call for ai required inspections. Complete drawing on reverse side. r <br /> X <br /> le: ��-f-r ... Date: <br /> Signed Tkt <br /> R DEPARTMENT USE ONLY <br /> App Ii. <br /> A epted byADate 1 -3 `� Area <br /> Pita Grout I 'tion by Final Inspection by <br /> ---�, - Dat Z �7 <br /> Addition omments: Lvp <br /> Applicant - Return all copies to: San Joaquin County Public Health may. <br /> 0 Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK$H RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> . e14 i� r OAC <br /> EH ,•xs <br />