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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DAIR ISSUED <br /> (Complete in Triplicate) f <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This f <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. L J! }A {(►�l(JI �, r �� <br /> Job Address <br /> 57Ya k), i l�(�,k`C't�L�.L�� �c _ City Lot Size/AcreagerISC1� <br /> � a - AAA �Sit_ <br /> Owner's Nam Address ���� � Phone�� 3r}_1'7 .� <br /> r �, V -7ItlLb� �ZZz� Phoneel[�b'� `�� <br /> Contract Address i License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR G OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK" 'Y SEWER LINES DISPOSAL FLD. PROP. LINE. t <br /> 1 � <br /> FOUNDATION �`AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation , Dia. of Well Casing ' <br /> * Domestic/Private ❑ Gravel Pack -❑ Tracy Type of Casing Specifications <br /> I'I Public El Other f (l Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Wel! Destruction O Well Diameter Sealing'Material & Depth <br /> Depth ller. Material & Depth <br /> TYPE OF SEPTIC WORK: NEW.INSTALtATiON I REPAIR ADDITION DESTRUCTION I I INo septic system permitted it public sewer is �3 <br /> evad_able-wit�hin 200 feet.) <br /> Installation will serve: Residence Commercial< OtherU.. <br /> Number of living units: Number edroo __11 <br /> Character of soil to a depth of 3 feet: A' —°� �`` Water table depth f <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance-to nearest: --Well Foundation� Property Line <br /> LEACHING'LINE';- - ❑ 'No. & Length of lines Total length/size <br /> FILTER SEDC- ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS., , ; - Depth f '-Size l�umbe► It _ <br /> SUMPS C3,,Distance to nearest: Well_1�` + Foundation- L.C"] + Property Line + <br /> DISPOSAL PONDS CO <br /> i !hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 " <br /> `rules and reguiations'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(l�\ <br /> r`-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 applican st call t r r wired inspections. Complete drawing on revers sl <br /> j . <br /> Signed X Title: r Dater <br />' - <br /> FOR DEPARTMENT USE ONLY Al.), <br /> Application Accepted by r !/'u�I-�stir �f/ ---- - Date —1 Area ;� 2 <br /> 6b Grout Inspection by Dated` r incl Inspection by Date2 <br /> Additional Comments: <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 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> 1. <br /> • EH 324(REV.1/N51 83,'3 <br /> / �� Ic <br /> Z � � � <br /> EH i4-26 1 <br />