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{ APPL I':,.. `I O*d FOR PERIL I T <br /> SAN AQUIN;`C6CWTY PUBLIC HEALTH IS4VICES <br /> -ENVIRONMENTAL, HEALTH DIVISION <br /> G. 1601 E HAZELTON AVE. ., PHONE (209Y-488-3420 <br /> I P ,0 BOX 2009, STOCKTON, CA .95201 <br /> PERI[I XP RE . _YEAR FROM_.DATE ,I.US.UBP F, n <br /> (Complete is Triplicate) <br /> Application is hereby made to San JoaquinCounty 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 w <br /> Joaquin County Public Health Services: <br /> Job Address { A r City�TbU _ Lot Size/Acreage, <br /> Owner's NameC. 9 q 369 Address .10�1 (A Phone l�k ��S s <br /> �Z l <br /> r l I - .. 7 bb� <br /> Contractor Lft'tut t ``ELLAddress `�aZ� w ' <br /> ' License No. Phone (� Z <br /> YPE OF WELL/PUMP: .NEW WELL ❑ WELL REPLACEMENT n .DESTRUCTION ❑ Out of Service. Well ❑ <br /> �DfL �D�fuC� -PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Monitoring well {� <br /> I TANGE TO NEAREST: SEPTIC TANK 1J.0�_ SEWER LINES '�5/ DISPOSAL FLD.--�7------- PROP, LINE <br /> FOUNDATION ^ AGRICULTURE WELL U1vt' OTHER WELL N{A_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS dr <br /> f} Industrial D Open Bottom ❑ Manteca Dia, of 11 Excavation Dia. of Wall Casing j <br /> N Domestic/Private 0 Gravel Pack ❑ Tracy. Typ o a. n . _ Specifications ! <br /> I'I Public f'1 Other n Della Dept f r t Seal Type of Grout' <br /> t I Irrigation _ Approx. Depth '.I 1 Eastern Su ea Installed by <br /> Repair Work Done 0 Type of Pump State Work Dana _ <br /> Well Destruction ❑ Well Diameter Seal, al & Depth <br /> Depth ial h-Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/A I ON'l I' DESTRUCTION I 1 o septi s stem permitted it public Y P p b c sewer is <br /> ' � i hl 200 Is A <br /> Installation will serve: Residence Commerc' Other <br /> Number of living units: Number of bedr ms <br /> Character of soli to a depth of 3 feet: star table depth <br /> SEPTIC TANK ❑ T e/Mf y <br /> YP g � ap i - N Compartments { <br /> PKG, TREATMENT PLT, ❑ 0 Method of Disposal <br /> Distance to ea st: Well Fou u. roperty Line <br /> LEACHING LINE 0 No. <br /> gth o in Total length/size <br /> FILTER BED 0 Distanc to are Well-. . dation Property Line. <br /> s <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to n rest Well Foundation Pro s' <br /> perty Line <br /> DISPOSAL PONDS 0 r ' <br /> I hereby certify that I have prepared this application and that the work wilt 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 laws of California•" Contractor's hiring or sub-contracting signature <br /> certifies the llotlowing: "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." ; k <br /> The applicarequ spections. Complete drawsng on re erre side. <br /> nt c t & <br /> Signed X for I Title, f Da <br /> .FOR-:DEPARTMENT usE ONLY Q <br /> Application Accepted by Dat ` Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ! <br /> Applicant - Return all copies to: San Joaquin County Public Health +� <br /> Services, Environmental Health Permit/Services ,7 <br /> 1601 F. Hazelton Ave., P 0 Box 2009, Stockton, CAs <br /> 95201CK <br /> FEE �� & <br /> NFO AMOUNT DUE AMOUNT REMtrTED CASH RECEIVED BY DATE PERMlT NO. q <br /> . ER17.24IREV.f�nSl <br /> FFi 14.7e <br /> �� VAlf <br /> { <br />