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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY"PUBLI'C HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH .DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 E <br /> P O BOR '2009,`'�STOCKTON; ''CA 95201' ' <br /> ;,,)HERMIT EXPIRES 1,1 YEAR(FROM .:DATE ISSUED <br /> I (Complete in Triplicate) <br /> Application is hereby made:to to Stin Joaquin Count for's f "ph r .., <br /> 1?p q y ermit'toconstruct'and%or install the work herein described. This <br /> application is made in compliance with-San Joaquin-.County.'Oidinance No?T549!and 01662 and the-Rules and-Regulations of San <br /> Joaquin County Public Health Services. r. J #s ^+, f, t .i •..i :.{. :p. .� F . i,h , <br /> Job Address ----.I- _7 L� _ i'I_u�r-� Ave-) K City' J o�� V�'r'Lat Size/Acreage I. <br /> V -2 <br /> Owner's Name ^J 61 _Jor7.14 al � _ ddress - . Z �� Ve ?QIP` � GSL Phone �~ .5'23 <br /> Contractor �f i _rli1E1�1 �u /Add ess `tle�Pc{ 8�t� Et)Q�-L icense [1. SW_Xs/ Phone 07-6 <br /> TYPE OF WELL/PUMP:. NEW WELL CA _ WELL REPLACEMENT_0- _ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR. p _ OTHER D 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 s/ <br /> n Industrial ❑ Open Bottom; ❑ Manteca _ Dia- of Well Excavation i_ 3 Dia. of,Well Casing �P Sly � <br /> ff,Domestic/Private [.Gravel Pack-#-- 0-Tracy--4--+-Type.of-Casing— - ��-• �-�- ��•Specifications <br /> I•I Public i 1 Other n Delta Depth of Grout Seal Type of Grout r i <br /> i I Irrigation Approx. Depth I l Eastern 1 Surface Seal Installed <br /> Repair Work Done _.__.._.= State--Work-Done 0 Type of Pump• <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth _Filler'Material. & Depth <br /> TYPE OF SEPTIC WORK; NEW INST-ALLATION l.I•*•REPAIR/A-DOITION"I-1 DESTRUPTION-i--1=INo septic system permitted if-public sewer is <br /> available Within 200 feet,I <br /> Installation will serve: _Residence_.'Commercial <br /> Number of living units: 5 Numbertof bedrooms i __ _i <br /> Character of soil to a depth of 3 feet: _ I Water table depth ' <br /> SEPTIC TANK. 0 -Type/Mfg <br /> Capacity `t "`-No..Compartments"- <br /> PKG. TREATMENT PLT, ❑ r r T _ _ ,Method of Disposal. <br /> Dist anca to nearest: Well Foundation, Property Line G <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED I=1 Distance to nearest: Well Foundation :Property Line G <br /> SEEPAGE PITS` 11 <br /> Depth 1 Size `Number, <br /> I <br /> SUMPS LI Distance to r <br /> nearest: '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 /> Horne owner or licensed agent's signature certifies the following: "I_c4rtify that-in-the performance-of_tha work tor-which:this permit is issued,.)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 Calitar <br /> The applicanr M call for air re ed ins i s. Complete dra g on reverse side. - J <br /> Signed X P I r D <br /> g Title" - ate: �(..�:.'9;_� <br /> r <br /> f. FOR.DEPARTMENt-USE ONLY .�....... <br /> x _ - __ ::. _•� L <br /> !�Application Accepted by ; Daae 7 Q tea ?�` _ <br /> Pit or 4 rout nspection by Date/! � inal.lnspec.tion by Date <br /> i ..j • <br /> Additional Comments: <br /> Applicant - Return all copies to: flan Joaquin County Public Health { <br /> tServices, Environmental-Health Perfdt/Services' <br /> `1601 E. Hazelton Ave., P ox 2009, Stockton, CA 95201 <br /> FEE <br /> INFO I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY m DATE' PERMIT'NO. ti <br /> a EH 13-24(REV,1/n51 - - x..i yl: <br /> EH 14.26 LJ <br /> - 90. 3 <br />