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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> I1 ENVIRONMENTAL HEALTH DIVISION � <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> IR _RMI'r EXPIRES 1 YEAR FROM DATE_ JLE�(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 compliancelwith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i1 - / <br /> .lab Address City , <br /> �`]rCC Lot Size/Acreage <br /> Owner's Name Oick '° AU- !i Address 9aC11& C.0. - ' QCr�_ hona <br /> Contractors� n[ ��.t.F1.fC�Address — <br /> License No. Phoned o') <br /> TYPE OF WELL/PUMP'.: NEW WELL ❑ WELL REPLACEMEl <br /> DESTRUCTION Out of Service Well ❑ <br /> M <br /> " SYSTEM-REPAIR'D '.+ + OTHER C3onitoring Well <br /> . PUMP INSTALLATION El � f <br /> DISTANCE TO NEAREST:,,SEPTIC TANK" SEWER LINES _DISPOSAL FLD, PROP. LINE <br /> -� !FOUNDATION AGRICULTURE WELLS _OTHERWEi:L—" PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS �` <br /> F_1 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation- t Dia. of Weil Casing <br /> 3 Domestic/Private L-1 Gravel Pack ❑ Tracy r'Type-of Casing—=�—� "' Specifications <br /> 1'I Public (1 Other ❑ Delta Depth of Grout.-Seal=- t Type of Grout ` <br /> I I lrrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump I H,P. State Work Done �4 <br /> Well Destruction C3Well Diameter Sealing Material & Depth 1 ,s <br /> Depth Filler Material & Depth ,%J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> t available within 200 feet.) + <br /> Installation will serve: Residence X#, Commercial Other ` <br /> Number of living units: Number of bedrooms E <br /> Character of soil to a depth of 3 feet: Water table depth <br /> i <br /> SEPTIC TANK. Type/Mfg' K Capacity - Na. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal I <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines ' Total length/size <br /> da ` <br /> FILTER BED n Distance to nearest: Well�� Foundation 10 a Property Line/0 <br /> SEEPAGE PITS J� Depth ---Size_Size Number_ <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ � i <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 Joaquinl County , <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance df 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 /> 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 mu t call for all requit inspections. Complete drawing onfreverse <br /> -side. -` <br /> Signed "` Title: Date: U '" <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by / Date (� Area <br /> Pit or Grout Inspection by Date Final inspection by Date 71 <br /> 'I,-$ <br /> Additional Comments: <br /> , <br /> Applicant — Return all copies tol;J San Joaquin County Public Health «` � 1 <br /> Services, Environmental Health Permit/Services <br /> i 1601 E. Razelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE ,1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMi7'N0. <br />' INFO J <br /> 1 � 5/�0 1q. -1Sg3 t <br /> . Ell A-26[REV.+/n5Y Z I <br /> EH:x•26 <br />