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y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> E%PIRES YEAR FR MDA E ED <br /> (Complete in Triplicate) <br /> Thi <br /> vork <br /> in <br /> Application is hereby made toSan wh iganC, o7oatqulnor a. permit to County OrdinancenNoruct 5k9aando1862stall and theeRules <br /> and eRegulations dof Sans <br /> applica <br /> tion is made in compliance: <br /> Joaquin County Public Health Services. <br /> 3 v S_ ,�c�s Y 22 city S <br /> .✓ Lot Size/Acreage <br /> I Job Address <br /> Owner's Name r�� L' u <br /> Address - S Phone <br /> t <br /> Gt9®ems Address 7 Al R aG=LAS r License No. �Y�Y76 Phone <br /> Contractor - <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C] Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP R ❑ <br /> OTHER ❑ Monitoring Well <br /> s DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION GRICULTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM REA CO TRUCTION SPECIFICATIONS Dia. of Well Casing <br /> f7 Industrial ❑ Open Bottom ❑ Manteca �a. of Well Excavation <br /> Specifications <br /> C_] Domestic/Private D Gravel Pack ❑ Tracy T-ype_of Casing y Tye of Grout <br /> r f'1 Public [_1 Other #t 3 f Delta - pth of-Grout Seal <br /> I Irrigation _ Approx. Depth I i Eas 5u a Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work bone _ <br /> ` Sealing Material Depth <br /> Well Destruction ❑ Well Diameter Filler`Material 8 Depth l� <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t DESTRUCTION I I (No septic s st m per feetifed if public sewer is <br /> t <br /> � Installation will serve: Residence�.I Commercial� Other <br /> \; Number of living units: Number of bedrooms <br /> iWater table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. D Type/Mfg �� ' S tet�'��� - Capacity No. Compartments <br /> P KG;L TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING-LINE --� 1 —No-B-4 ngth of lines © ' Total length/size <br /> !. rr / <br /> FILTER BED Ell Distance,to nearest. Well' �� Foundation Property tine <br /> .�� � <br /> SEEPAGE PITS I _ Depth ! Size= -Number _ <br /> I SUMPS Li Distance to nearest: Well Z 69 67 Foundation <br /> /B 0 r r yr Property Line I a <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will b6 done in accordance with San Joaquin county ordinances, stats lawsand <br /> rules and regulations of the San.Joaquin County <br /> "I certify that in'the peitormance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: <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 <br /> compensa-tion laws of California." ' <br /> The applicant must call for all required <br /> inspections:. Complete drawing on reverse side. <br /> Gt�rr Date: <br /> Signed X_._. _ Title: <br /> FORIDEPARTMENT USE ONLY � <br /> Application Accepted by CLO c",I <br /> LIX-Li Data � d-�_ Area <br /> ` Pit or Grout Inspection by i�- w = Date Final Inspection by Date <br /> Additional Comments: F y <br /> r <br /> � Applicatit - Return all copies to:. San Joaquin County Public Health <br /> —J Services, Environmental Health Fermat/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED '' CASH RECEIVED BY DATE PERMIT'NO. <br /> _!E!� <br /> . Eli 13-24IREV.riNsrNFO I ff •J �t� 'tiV e4L1 �� � � Q / <br /> EH 1426 , - <br />