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APPLICATION FOR PERMIT <br /> SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46 <br /> 8-3420 <br /> P 0 BOX 2009, <br /> STOCKTON, CA 95201, <br /> . . . ) E P <br /> 21"JIT EXPIRES 1 .YEAR FROM DA ISSUED S <br /> (Complptd�jnjripl, tt e) -,,,EN � M HE <br /> VWRONMrN. <br /> Application is hereby made.to San Joaquin county for a permit to construct and/or install the work�a�am&W%y is <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules <br /> and Regulations of San <br /> Joaquin County Public Health Services. <br /> figV 3 9- WINGLrWrIE RO IV9-.21 Av-vr-- <br /> ,$r2 AW 7;e* <br /> CityA 33V YISWA4W IP44N <br /> Job Address 'au / Lot Size/Acreage 41.SEAWMT <br /> , <br /> WW6: � AP- <br /> Owner's Name Di�E 6 <br /> ContractorC34UV247aZb9&MdC*Tdress(7X S. K1490C <br /> "Kense No.M2U.77 'Phone _1��7 <br /> TYPE OF WELL/PUMP: NEW WELL>K, WELL REMLACEMENT 0 DESTRUCTION 0 Out of.Service Well 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER ❑ Monitoring Well CD <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDPROP. LINE -- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL,3=. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> .Pf-Domestic/Private Gravel Pack L3 Tracy Type of Casing '4?K dGY-, 92 Specifications- <br /> C) Public 1-1 Other Pt-Della Depth of Grout Seal /1570jP= Type of Grout <br /> I f Irrigation —/3—Approx. Depth ( ) Easterh' Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial- Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation— Property Line <br /> LEACHING LINE L) No. & Length of lines Total length/size <br /> FILTER BED F) Distance to nearest Well Foundation--- Property Line <br /> SEEPAGE PITS 11 Depth Size.— Number <br /> SUMPS Cl Distance to nearest: Well, Fo6ndation 1 Property Line <br /> -DISPOSAL PONDS 0 --- I - . - .,- <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 rpanner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I ce ify 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 California." <br /> ,6 <br /> The app�i a t s If f <br /> all req r ins ctions. Complete drawing on to a so side, <br /> Signed <br /> Title: IWO el -Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by pate Area 4s, <br /> '�'n�v <br /> Pit<G Grout I ction by Dat®r:o:tjt>I- Date <br /> Additional Comments: C41 IPA/ AP1Y ,w// T // If' //V. <br /> ( 1 1 <br /> Applicant - Return all copies to: Sall Joaquin County Public Health 55f64q, <br /> Services, Environmental Health Permit/Services )7 <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PEAMIT'NO, <br /> EH 13.24(REV. IA 51 <br /> EN A-25 <br />