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APPLICATION FOR PERMIT <br /> t pu <br /> SAN J'OAQU.IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVJ IaNMENTAL \AEALTH DIVISION <br /> 1601 E. HAZE],TON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> P UWIT EXPIRES 1 YEAR FROM DATE ISSUED ,riQG�174Y <br /> I� (Complete in Triplicate) [J[37 <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 1$62 and the Rules and Regulations of San <br /> Joaquin.Ceunty Public Health.Services. ��]7 <br /> Job Address e r City Lot Size/Acreage 41 f <br /> Owneir's Name 6,4F— I Address %31 7 Phone <br /> 4 ��// pp jj <br /> Contractor Address ZZ/A1,151 �� License No. �/ Ja¢/�Phone � 1 <br /> TYPE OF WELL/PUMP: 11 NEW WELLA WELL REPLACEME T M DESTRUCTION 0 out of Servlce,�We31�/.0, <br /> PUMP INSTALLATION f SYSTEM REPAIR 0 OTHER 0 Monitoring-We'll FU <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, --r PROP. LINE l� <br /> i <br /> FOUNDATIONS AGRICULTURE WELL ---'OTHER WELL , PITWSUMPS <br /> Y' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO v <br /> V� <br /> X <br /> dustrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing / 0omesticlPrivateGravel Pack t C7 Tracy Type of,Casing �_rSpecifications ublic Cl Other' n pelta '" —Depth of G,u sal Type of Grout j <br /> sy— <br /> II Irrigation awappfox. De' th I I astern ujfce Seal Installed by <br /> Repair Work Done 0 Tyaof Pump I H.P. State Work Done <br /> Well Destruction O Well Diame r € Sealing Ma �ki4T& �ptti� <br /> Depth `f; 3 Filler Material i Depth 5� 1 <br /> TYPE OF SEPTIC WORK: NEW INSTfAI ', TION I 1 REPA: /it—b rI5 1-l-', DESTRRUCTI-ON-111 lNd�sepfic s-s-tem permitted if public sewer is <br /> Il� •v-- —µ ar`able'"w`ithin 200 feet.l <br /> Installation will serve: Residence ' ommercial_ Other - ---I �`�� <br /> Number of living units: Nu�mr6eriiIf bedrooms <br /> Character of soil to a depth of 3 fept1atarcCtagle depth A� <br /> SEPTIC TANK. 0 Type/Mfg Capacity �f�t:Ompart nts <br /> A G. TREATMENT PLT. 0 �� ,,.�-. --�_ �^ Method of-Disposal 141, <br /> Distance to nearest: Well '—fo atto f`�P_roperty Line <br /> LEACHING LINE D No. & Length of lines tel la /size r f I <br /> ,I <br /> I FILTER BED 1-1Distanceto nearest: Well Foundati n'� f V Propert bine <br /> SEEPAGE PITS 11 Depth Size _ Number [ <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS © II <br /> 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 IsiQnature 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 mariner as to become subject to workman's compensation laws 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 /> ,I <br /> The applicant a 1 requ' I ons. Complete drawing on re er Side. <br /> ,f I �- <br />' Signed X Title: A—AVDate: v <br /> I 1 i <br /> FO DEPARTMENT USE ON <br /> i q <br /> Applica ' ccepted b�1U <br /> Date Area <br /> _ `� Area <br /> Pit or iGrou apection Datb Final Inspection b :�"."� DatJ U <br /> i <br /> Additional Comments: !I i <br /> i 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 95201FEE ��J\ <br /> INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ] PERMIT'N0. <br /> • EEH Ht4.2pIAEV.FiHss ( ' [fCJ71 <br /> Il <br /> p i <br />