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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PIISLIC HEALTH SERVICES } <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE {209)468-3420 <br /> P 4 SOX 2009, STOCKTON, CA 95241 <br /> FERMIT RBS 1 YEAR FRQXZ?AT9 ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made•to $an JcagNin- County for a Perm-it to c=Atmitt and/or install the work herein deserihcd. This <br /> application is made in cotw)-iasace wlth'San Joaquin County ordinance No. 549 and 1862 and the Rules arid RegulAtiona of Llan <br /> Joaquin County Public Health Services. <br /> Job Address� � ]t5 �UL�„�e GrGf n 1r C;Ty �I�O:IJ_ _ �ot Size/Acreage <br /> Owner's Name SIUt 1>tr t �� Address - Phone <br /> COrtlrati0r '_ 4 F AQds&$S d f�i�r/ f If{I License NoPhone ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ❑ESTRUCTION r=7 out of Service Yell ❑ <br /> PUMP INSTALLATION Q SYSTEM REPAIR Q OTHER n Monitoring Well 0 <br /> DISTANCE TO NEAREST; SEPtIC TANK SEWER LINES DISPOSAL FLU. PROP- LINE <br /> r' ; FOUNDATION. AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> NTE14DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F! Industrial ❑ Open Sottorn ❑ Manlecs Dia. of Well Excavation Dia. of Wal!Casing <br /> N Dornewicl Private Q Grave! Pack ❑ Tracy Type of Casing Specifications <br /> t-1 Public 1'1 Other r C1 Delta Deplh of Grout Seal Type of Grout <br /> IrriOasian —Approx,-Depth I I Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. $lata Wprk Dong _ <br /> Walt Destruction 13 Well Diameter Sealing Material i bepth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION AEPAlRlAfJ>1tTtQN 1 IDESTRUCTION i I !No septic system permitted if public sewat is ❑ <br /> avai"le within 20Q leet.l <br /> Y . <br /> lnstailatian wilt serve: Residence____ Commercial— Other <br /> Number of Timing units: --(-- Number of bedrooms <br /> Character of¢cel to a daprh of 3 Feel: t Water table depth <br /> SEPTIC TANK ❑ Type/Mjl '� Capacety-20"d`fl No. Compartments <br /> PKG. TREATMENT PLT. Ci 1` �� r �'� Method of Disposal <br /> Distance foo.nearest: Well y`" L Foundation14 Property=Line �d <br /> LEACHING LINE " � No. dr Length of lines Tglei lengthlsii@ � <br /> v <br /> FILTER BED ❑ Distance to nearest: WO�_ Foundation Property Line �!g r�)-O�� <br /> SEEPAGE PITS I i Depth -1J }E•rZ4 Numtrer <br /> ! -SUMPSDistance to naarew: Well Foundation Argperty Line S`D <br /> DISPOSAL PONDS Cl <br /> I hereby certify Ihat I have prepared this application and chat She work witl bi-done in 6ccardance with San Joaquin county ordinances,state laws, and �. <br /> Pules and regulations of the San Joaquin County <br /> Nome owner or licensed agent's signature certifies the following: "I Certify shat in the performance of the work for which this permit is sssusd, I shall nor <br /> ampioy any paregn in such manner of to become subject to workrnan:s compensation laws of California Contractor's miring or sub•contraetin$signature <br /> cartifies the lollow nq; "I certify that in the partormanes of the work for which this permit is Issued, I shalt employ perWns subject to workman's companso- <br /> tion laws of California." <br /> The applicant must cast foro MKrad irs6pactions: Complete drawing on reverse tide, i <br /> Signed r / 7It4e; Date: <br /> OR D ARTME SE ONLY <br /> Application Adapted by Date <br /> Pit OF Groat Inspection by Date Final Inspection by Dat <br /> Add tiorW Comments: <br /> APPlics,nt - Return eft orgies to'- San J01KUin County Public Health <br /> Services, &xviroomental Health PermitlServl.Cea <br /> i6oi z. Hazelton Ave., P Q Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT OUE AMOUNT REMME6 CASH RECEIVED BY GATE 11 PFRMt-T N0, <br /> rREV.7rn <br /> f 4 p <br />' tri 14.211 00 <br />