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APPLICATION FOR PERMIT <br /> �8 e <br /> r _ > <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> k 1601 E. HAZ£LTON AVE. , PHONE (209)468-34120 <br /> ` P O BOR 2009, STOCKTON, CA 95201 <br /> E[ REMIT EXPIRES„1„YEAR FROM DATE ISSUED Zj._ �yQ <br /> I - � �� ,p (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 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. <br /> CaQ�mer) 0-71- 1-30 -11 <br /> Job AddressCity Lot Size/Acreage <br /> ' Owner's Name Airolg .S Address �35�J Nr 41764 ;o ,AJI�PV`e_ Phone <br /> Contractor t ess -ZBZS ! s Y!lY2Ta-_5-Aicense No. Phone g—/3y <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-., 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. RR �QST <br /> FOUNDATION AGRICULTURE WELL OTHER WELL .RIZZeTW*P&- !! ✓al <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ON Py1i�S/ r+L <br /> SZau.f,/11 ,� <br /> f 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation •-9ier-eFiM1�eF � <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing *fpoci#+eatierl ”' Z1Gd 46ZY 06 <br /> I-I Public 1:7 Other ❑ Delta Depth of Grout Seal s.a$.0 eF►t� Wl <br /> I I Irrigation Approx. Depth ( I Eastern Surface Seal Installed byAl <br /> � <br /> Repair Work Done 0 Type of Pump H.P. State Work Done rx'u <br /> Well Destruction 0 Well Diameter Sealing Material & Depth -� <br /> Depth Filler Material & Depth { <br /> j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDETION i I DESTRUCTION I I INa septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I 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 /> 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r � <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED C-1 Distance to nearest: Weil Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> r SUMPS f l Distance to nearest: Well Foundation Property Line <br /> f DISPOSAL PONDS Cl <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 <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 <br /> 7 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 /> I The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: / N6 z Date: ` <br /> k R DEPARTMENT USE ONLY -j <br /> [ Application Accepted 4y Date i Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 2 w C7 <br /> k Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public 'Health <br /> Services, Environmental Health Permit/Services <br /> it <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT fiEMt7TED CASH CK I RECEIVED BY DATE GPERMI7 NO-1.9 `9 <br /> . EH t3-z.tnev.I s, 01,v-2 r 'a� Zd �C> ( C `L <br /> EH 1446 <br />