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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> j RES 1 YEAR FROM DAIE JQaUED <br /> I <br /> (Complete in Triplicate) <br /> Application is here trade to San Joa uin Count for <br /> pp by q y permit to construct and/or install the work herein described. This <br /> application is trade in compliance with San Joaquin County Ordinance No, 549 and 1$62 and the Rules and Regulations of San ( I <br /> Joaquin County Public Health Services. h W <br /> Job Address City Lot Size/Acreage� �? -- <br /> Qwner'S.Name 4ddre}ss, Ahwl4�! Phare <br /> Contractor &_A1 &6� KI-C. Addresl_�, G :Q�� ceesNo �_Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLD:' "' 'PROP: LINE <br /> } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSr <br />' C3 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack-4 ❑ Tracy Type of Casing Specifications <br /> I'I'Piiblic Cl OtherCl Delta Depth of Grout Seat Type of Grout <br /> I I if', ation �. .. i —..Approx. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump i H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material de Depth <br /> I Depth ' Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION K REPAIRlADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> r ' available within 200 feet.) <br /> Installation will serve: Residence— !Commercial_ Other <br /> Number of living units: j" Numberofbedrooms <br /> -Ali% Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. Type/Mfg i Capacity&2i�4*219LNo. Compartments <br /> j4 PKG. TREATMENT PLT. ❑ w._ „ " Method of Disposal + <br /> ! Distance to nearest: Well Foundation Property Line 492ki2� <br /> 1 ,! <br /> LEACHING LINE P5�,No. & Length of lines 4 �iX Tgtal length/size i <br /> FILTER BED C) Distance to�nearest- Well f�i�TFoundation l�' f Property Line ! <br /> f <br /> SEEPAGE PITS Depth Size Number <br /> / SUMPS U Distance to 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 /> Home ownei:or licensed agent's signature:certifies the following: 71 certify that in the performance of the work for which this permit is issued, I shall not <br /> I <br /> employ any person in such manner as to become subject to wdrkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance f 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 requir ins ctions. Cc late drawing on reverse side. <br /> T <br /> S' ed �C ' Title: . ' Date: <br /> t R DfPARTMENT USE ONLY <br /> l Application Accepted by C"^� Date t Area <br /> F <br /> #Pit or Grout inspection by Date Final Inspection by Date <br /> Zb-2A <br /> s s <br />'i Additional Comments: j <br /> #Applicant - Return all copies to: San Joaquin County-Pub.lic'•Health <br /> 'Services, Environmental Health Permit/Services <br /> 1 <br /> 1601 E. Hazelton.Ave.., ]? O 'Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> + Em 13.24IREv.Hiss) .011, <br /> EH 7628 <br /> 4 <br />