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w" �►� APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p 0 E. BOX 2009�,v —3420 <br /> STOCKTON, CA 95201 <br /> f <br /> P EXP11RES 1 PT.AR 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 vork herein described. This <br /> application is made in coupliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City 7bCK7-&- Lot Size/Acreage <br /> Job Address -- / T <br /> �r9-F� Address 4 �`L'g N O � C� 9 SGC O Phone �'�S"BQ/�3G <br /> Owner's Name 3Ci14 E,Sul r,E r4 6 <br /> Q OjP/y 31 <br /> t rriV t: �. Address I�,O j C�R061V . �A license No. 1-1174 a* Phone <br /> Contractor rJ 1� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ i <br /> OTHER O Monitoring Well i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O ! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IN <br /> O Open Bottom Excavation /�___ Dia. of Well Casing <br /> O Manteca Dia. of Well <br /> n Industrial Specifications iG L I <br /> C.1 Domestic/Private O Gravel Pack O Tracy Type of Casing <br /> Delta Depth of Grout Seal <br /> I'1 Public (I Other fl <br /> TY Grou A/a 6/16NT ' <br /> I 1 Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by <br /> of Pump H.P. State Work Done_ <br /> Repair Work Done Ll Type Sealing Material i Depthfke—r--- <br /> Well Destruction O Well Diameter.410 F-T Tiller Material i Depth — I <br /> Depth .-11�+.,// <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION 1 I ailable�within 200 feetystem .) it public <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 fast: <br /> . <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments C� <br /> Method of Disposal <br /> PKG. TREATMENT PLT.O (� <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> + <br /> SEEPAGE PITS 11 Depth Sirs Number s <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> a <br /> DISPOSAL PONOS O <br /> 1 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,1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hirin su ntracting signature <br /> certifies the following:*1 certify that in the performance of the work for which this permit is issued.I shag employ <br /> �ub� rkman's compensa- <br /> tion laws of California." ( 1 v <br /> The applicant mus a for all required inspections. C eta drawing on reverse side.� '01 <br /> .Signed <br /> Title: Date: <br /> 1 FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> ,'`,�,/ Date {- �7! Area <br /> tt 444 <br /> Pit or Grout Inspection by Date Final Inspec'on by Date <br /> Additional Comments: <br /> Applicant – Return s]1 copies to: Ban Joaq County Public Health <br /> Services, Envirommente.l Health Permit/Services <br /> 1601 E. Hazelton Ave.. p 0 Box 2009. Stockton. CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ,,RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> • EH 13.24IREV.I/"S1 <br /> EH 4.20 <br />