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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-34-20 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> [ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 /> Job Address 5�.3 2 tt.Lo Cit Y ! �[m,J Lot Size/Acre e <br /> !X - -- <br /> 1 ikk <br /> X Owner's Name . I t t--� t A,4,1 10;4 c L14°K dress '141-2 5;64F WAlt#L G< Phone <br /> I\ �j8o_Lr. j fI Address�dz f �� e���fl'� IAS •License No. 3�12-3 (' Phone ^C0pf <br /> Contractor _ !!! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ­ - OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domestic/Private ❑ Gravel Packr: ❑ Tracy Type of Casing Specifications <br /> i'I Public Ia Other , n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump ? H^P. `' ! State Work Done _ <br /> Well Destruction ❑,r. Well Diameter. Sealing Material & Depth <br /> Depth R I Filler MateriaY l Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION i I lNo septic system permitted if public sewer is' <br /> available within 200 feet.I <br /> Installation will serve: Residence" Commercial Other <br /> Number of living units: Number of bedrooms w ; <br /> sem... <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg:-11 `Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r� m <br /> ,�, Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> 41- — ,...., .- . - -. _. <br /> LEACHING LINE ❑ No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance tpinearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS CI Distance tornearesV Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 mannee as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> 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 applicant must call for'all required,insp oions. Complete drawing on reverse side. <br /> ''v <br /> Signed t W[ Title: %—A—Xn +t`6 Date: AWAAC_d4• A�I?�l`�o <br /> XIkPXTMENT USE ONLY <br /> Application Accepted by _ 4Date �� u Area <br /> Pit or Grout Inspection by Date Final Inspection by Date' 1 <br /> Additional Comments: q k <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 <br /> INFO AYOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. y <br /> + EN 13-24 1REY.I/N 5! <br /> EH 54.2E <br />