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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION I < <br /> 1a 1601 E. HAZELTON AVE. , PHONE (209)4683420 <br /> P O BOX 2009, STOCKTON, CA 95201V� ,v-�-Q�\ . <br /> PEMIT 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 /> YJob Address �V ' L.t/ City A.� Lot Size/Acreage _ <br /> Owner's Name�`ta�/�tC Vi I �Ao� Address j�•��f I:��s/ r�,�n�� Phone <br /> . �Pd A/ <br /> X Contractor OURY ='_ A4,w Address f2foa� License No. , �6 Phone L <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring Well <br /> DI E TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYP ELL PROBLEM AREA CONSTRUCTION SPECIE NS <br /> Cl Industrial ❑ Open BottomManteca Dia- of We ation pia. of Well Casing <br /> [1 Domestic/Private G7 Gravel Pack ❑ Trac ype of Casing- Specifications <br /> C1 Public fa Other a th of Grout Seal Type of Grout <br /> I I Irrigation _.A epth l I Eastern Surface nstalled by <br /> Repair Work Done ype of Pump H.P. tate Work Done <br /> Well Destructio ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I (No septic system permitted it public sawot is <br /> available within 206 feet.) r. <br /> Installation will serve: Residence X Commercial— Other <br /> Number of living units: /., Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg 9Capacity No. Compartments / <br /> PKG. TREATMENT PLT. C1Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines r Total length/sire <br /> FILTER BED C) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS It Depth Size } Number <br /> SUMPS LI 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 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 shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or subcontracting 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 Calif . <br /> The appticant u ca r all rYad ins 0ions. Complete drawing on reverse side. <br /> Signed Title: ._ ! Date: _ L `�J 6 <br /> F DEP=:t_ <br /> ONLY <br /> Application Accepted by Date t� Area <br /> Pit or Grout Inspection by Date Final Inspection by / Date 7 1d <br /> Additional Comments: / n 1i <br /> mw u <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Lnvironmental health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> Eso <br /> AMOUNT DUE AMOUNT R//EMITTED CASH RECEIVED BY DATE �p PERMIT-NO. <br /> . EH f3.2�IREV.�iwsl I�1,�� �d I r I� •3• [1 -4� <br /> Eft t -26 [( L <br />