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. I <br /> . I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> XP RES 1 YEAR FROM DATE ISSU # ; <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> � 1 <br /> �ale City Lot Size/Acreage <br /> Job Address <br /> Address_ 0� & /,f Phone <br /> Owner's Name VJ �yr� / <br /> I �TTJ +r�'�FGt,�/ /lt' � ✓ld C'�License No. �7�y phone <br /> k Contractor ! Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ng <br /> c) out of Service <br /> Well li <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> DISTA T: SEPTIC TANK�SEWER`L•INES""'^-'�""` ^` "'DISPOSAL FLD.--' LINE <br /> FO AGRICULTURE WELL OTHER PITS/SUMPS <br /> i1 INTENDED USE TYPE OF WELL PROS <br /> CONST ECIFICATIONS <br /> C1 Industrial E) Open Bottom ❑,Manteca <br /> ell Excavation Diaof Well Casing <br /> . <br /> C] <br /> Domestic/Private. ❑ Gravel Pack Type of Casing Specifications <br /> I'1 Public fa Other !-1 Delta Depth of Grout Seal Type of Grout <br /> t <br /> II Irtioation _.Apprtix. Depth -1 1 Eastern, Surface Seal installed by <br /> Repair Work C1 Type of Pump - H:P. State Work Done s <br />` ► *~ ' Sealieg Material & Depth r <br /> Well D ruction ❑. Well Diameter 1� ,_ <br /> Depth '1`tFilleMaterial & Depth <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION REPAIR/ ave ADDITION I 1 DESTRUCTION i I septic system permitted it public sewer is <br /> � available within 200 feet.) <br /> Installation will serve: Residence-jK Commercial <br /> Number of living units: Number of be roots � G7 � � ! r <br /> Character of soil to a depth of 3 feet: �� t _ Water table depth <br /> o._Compartments <br /> SEPTIC TANK ❑ Type/Mfg f't Capy�^ , <br /> PKG. TREATMENT PLT. ❑ t r Method, Di <br /> sal <br /> Distance to nearest: Well /vim Foundation Property line f Q t <br /> k, a <br /> LEACHING LINE 0 No. & Length of linesT'`al length/sire <br /> QQ , <br /> FILTER BED Cl Distance to:nearest: Well �--- FoundationProperty Line _ <br /> SEEPAGE PITS t I Depth --Sire 2 Number +3 <br /> SUMPS LI Distance to nearest: Well Foundation` Property Line` 0 c <br /> + DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordpnce with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County A ,. . <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the periormance-of the work for which this permit is issued, ! shall-not <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 compensa- <br /> tion laws of California." <br /> The applicant t call r all re ui inspections. Complete drawing on'reverse.side. <br /> Signed X - — Title: <br /> (�GU"�$i� � Date: 'l�✓4 <br /> 9 <br /> ' A DEPARTMENT USE ONLY ( `` Q <br /> Application Accepted by a Date `p�ULCI - - — Area <br /> 4 it or rout InspectionTy _ D to ! j Final Inspection by. Dst l <br /> _ _.N <br /> + Additional Comments: 4I L, t-- <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH VI gEj, DATE PERMIT'N0. <br /> �(°�EH 11.21 IREV.�ia+si V'' Al <br /> �,.� Q q �t.J�s+`' <br /> EH 14.11 L 1 <br />