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APPLICATION FOR PERMIT Alto P7 <br /> SAN JOAQUIN-COUNTY ,PUBLIC HEALTH SERVICES <br /> ENVIROXMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON "AVE., PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> T!JRXIT EXPIRES 1 YEAR FROM DAJE ISSUED <br /> (Complete in Triplicate) i <br /> I <br /> Application is hereby trade 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 Services. <br /> Jab Address T City �pL_.tot Size/Acreage <br /> Owner's Name �~ Ir Address 1 Phone 931-461? <br /> -1 Z <br /> -C 5 7 ; <br /> dip 7 6- 6 <br /> Contracto �w. Address .g f'��C � License No. Phone 1 <br /> TYPE OF WELL/PUMP: F4EW WELL © WELL REPLACEMENT GK DESTRUCTION &Mt of Service Well 0 <br /> PUMP INSTALLATION C 1 SYSTEM REPAIR ❑ OTHER ❑ MonitoringWello <br /> DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> iFOUNDATION AGRICULTURE WELL OTHER WELL.V'_ PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n In�Sstria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavationr^� pia. of Well Casing j <br /> W Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing lite specifications <br /> 1'] Public 1-1 Other 1-�11//Delta Depth of Grout Seal T pe of Grout <br /> I i Irrigation _.-Approx. Depth ITEastern Surface Seal Installed by 'AJ <br /> Repair Work Done 0 Type of Pump H.P. State WDpr�e _ <br /> Well Destruction Well Diameter _ Z Sealing Material & Depth <br /> Depth Q � Filler Material dr Depth Jam' <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION # I (No septic system permitted if public sewer is "h <br /> available within 200 feet.] <br /> Installation will serve:"`Resident a-_ __ <br /> Number of living units: Number of bedrooms _ ! <br /> Character of soil to a depth of 3 feet: '^ t�? Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PET. ❑ : Method of Disposal <br /> r j i Distance to nearest: Well Foundation Property Line i <br /> 4 <br /> LEACHING LINE Ll No. Total length/size <br /> FILTER BED l'❑ •Distance to nearestt Well Foundation Property Line <br /> SEEPAGE PITS w i -LII "DepthSize ' Number 1 <br /> SUMP5 CI Distance to nearest: Well Foundations Property Line <br /> DISPOSAL PONDS----- Q_ <br /> I hereby certify,that I have prepared this application and that the work will be ddne in accordance with San Joaquin county ordinances, state laws, and <br /> rules and nigulatftins of the San Joaquin County " 4 <br /> Home owner or li s si nature cern#ies_the-fo]lawin f <br /> g g:-"1 certify that in the-performance of the work for which this permit is issued, I shall not <br /> empioy.00 p`a`ori in aucfi ins` er as to become subject t orkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the f lowing: "!certify hat in the rman f e work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws o CaII(orn' <br /> s <br /> The appli nt u call f all re it m to drawing on ids. <br /> Signed Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date / Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: Sap Joaquin County Pu c Health <br /> Services, Environmental ealth Permit/Services <br /> 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 � �j Yi ��/-a5 C! <br /> INFO FEE AMOUNT DUI AMOUNT REMITTED CK V CASH RECEIVED BY DATE PERMIT NO. , 1 <br /> . EH13-24 InEV. <br /> EH 74.28 ! A ,QC) <br /> 1 <br /> f <br />