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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 BOR 2009, STOCKTON, CA 95201 <br />EXPIRES 1 YEAR FROM DAT <br />f <br />(Complete in Triplicate) VfRQNkA[NTQ[ HEALTH <br />Application is hereby made,to San Joaquin County for a permit to construct and/or install the vopkftell4t'8Ucjk4d. 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. , ?,?g C? 'y - <br />r,-1 - in awl ' -el ,AJA 1 t f t (Ai va f 1� r;,.,� f,P�(1 Lot Size/Acreage 1 J Y !CC r"C y <br />Jounuur osa --11 ­ / � _ — _ <br />Owner's Name �r 16 -FA C' Address ® .,60X 6 �G+ 36k - <br />"grHt, S1-,� r�i1 PhoneC7>�l <br />Contractor T r (Icv" Address dC (,Vr1 License No?/ 2,2,b3 Phone 13Y1S� <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION A Out of Service Well O <br />PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANK .7 SEWER LINES !' DISPOSAL FLDZ5 PROP. LINE152 MW - <br />FOUNDATION AGRICULTURE WELL`�� OTHER WELL'` LPITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />CI Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br />F l Domestic/ Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br />I'I Public Cl Other FI Delta Depth of Grout Seal Type of Grout <br />I I Irrigation _ Approx. Depth I I Eastern Surface Soul Installed by _ <br />Repair Work Done U Type of Pump �1 H.P. State Work D ne _ -— <br />Well Destruction Well Diameter oe Sealing Material & Depth rPI <br />Depth - e f)'� Fi lfr Material & Depti{'t.. -fL�Nt n�1 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is <br />available within 200 feet.) <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 O Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. O Method of Disposal <br />Distance to nearest: Well Foundation _ Property Line <br />LEACHING LINE L1 No. & Length of lines Total length/size t <br />FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS I 1 Depth Size _ Number <br />SUMPS LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS O <br />1 hereby certify that I have prepared this aoolication and that the work will be done in accordance with San Joaouin county ordinancesstate laws. an <br />rules and reg ons of the San Joaquin County <br />Home own censed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br />employ any rson in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub -contracting signature <br />certifies t 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 applicant t 11 for all re qui spections. Complet drawing on rev rs id.0 <br />Signed X oeZu Title: Date: • %3 �' _ <br />! FOR DEPARTMEN USE ONLY <br />Application Accepted by t!G^t°Gc 6� Date / Area 2 / 7 <br />Pit or Grout Inspection by Date Final Inspection by / Date la o <br />Additional Comments: <br />Applicant - Retuin 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 />. EH 1324 tREV. I/ x s; <br />EH '4.26 <br />FEE INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK <br />RECEIVED BY <br />DATE <br />PERMIT' NO. <br />N <br />