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APPLICATION FOR PERMIT <br /> SAN JOAQTJIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 44) 1601 E. SAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> {` PXAMIT 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /�,��� <br /> f{O� 4 . City6&:_�;b C �Uot Size/Acreage <br /> Job Address � <br /> *� ry/� /✓M Address � r r phone <br /> Owner's Name _,4.. p� v <br /> Contractor <br /> Address � � License No. ICY Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ rWFLL REPLACEMENT `DESTRUCTION 0 Out of Service Well 0 <br /> f Monitoring Well C1 <br /> PUMP INSTALLATION ❑ � '�SYSTEM REPAIRjL] .1 .�. OTHER C) i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINER SINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT ER WELL PITSISUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ONSTF�,UCTION SPEC FICA-TIONS I <br /> F) Industrial ❑ Open Bottom ❑ Manteca Dia.`of Well Excavation 'r ^;, Dia. of Well Casing <br /> ?% . y <br /> Cl DomesticlPrivate ❑ Gravel Pack n Tracy Type a L'88in'� -- Specifications <br /> I"1 Public C] Other fl Delta Depth of Grout Seal Type of Grout <br /> , <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed_b� r I <br /> Repair Work Done U Type of Pump H.P. t Siar Work Done _ <br /> Sealing Material 16 Depth <br /> Well Destruction ❑ Well Diameter <br /> ' Depth Filler Material 8 Depth , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION -D.ESTRUCTION-f I INo septic system permitted.if public sewer is <br /> V° # t„`t +. available within 200 feet.! I <br /> Installation.will serve: Residence Commercial '"/ O+�ther�!_�� <br /> Number of living units:, 1 Number of bedrooms <br /> Character�of soil to a depth of 3 feet: oe - . !:!,-Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity **(No. Compartments <br /> PKG. TREATMENT PLT. ❑ r " ^---__r_ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation � Property Line <br /> LEk&ING LINE ❑ No. & Lengith-of lines �� Total length/size_ <br /> FILTER BED 4 ❑ Distance to nearest:" Well rFoudation !f roperty Line 0 <br /> SEEPAGE PITS # 11 Depth _ 5 - Sire �` Numbe� <br /> SUMPS r Cl Distance to nearest: Well__Z '!Foundalion�d/� r -- roperty 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 she not <br /> S� <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contfacting signsZore-y' <br /> certifies the following: "I certify that in the performance•of-the•work.-for-which-this.permit.isissued,,l_shall employ-persons subject to workman's compensa. <br /> tion laws of California." _� r <br /> The applic t m call for 1 m <br /> ed inspeetio s. Coplete drawing on teversei side. � I <br /> ' - <br /> Signed Date: <br /> (� <br /> -Title: . <br /> ' FOR DEPARTMENT USE ONLY ea i <br /> Application Accepted by 1_h^ Date y Area <br /> a <br /> r Grout Inspection by n^ Data Final Inspection by �^ Date ©-2-lo <br /> v <br /> r <br /> Additional Comments: e k Cir 1 I n k( h6 19 <br /> Applicant - Return all..pies to: San Joaqui ty Public Health <br /> Services, Environmental Health Permit/Services <br /> ,1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. <br /> INf0 CASH <br /> b <br /> • ♦ Eli 13-244REY.1/85) -Za��.y} )ps (.-S-�(� l-'P- <br /> 43> <br />