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s x <br /> APPLICATION FOR PERMIT / <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH WRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$3420 <br /> P O BOX 2009, STOCKTON. CA 95201 <br /> PEMIT EXPIRES 1 YEAR FROM DATE IgSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health ,,Services. <br /> City +�F C Lot Size/Acreage <br /> Joh Address <br /> Owner's NameM^ FT C', P Ul!" Address _PQ c2ak71Phone GU�f- �� 72-71, <br /> Contractor Sr�� P_6—4",$'T�t4)t±l�.f �Address G <br /> (civ ,2 Q� . icense No. �4 d Phone 637- 79 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION LJ of Service ue11 ❑ i <br /> PUMP INSTALLATION C3 SYSTEM REPAIR C3OTHER ❑ Monitoring Well 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK Nr' SEWER LINES _tLjer DISPOSAL. FLO.-4 PROP. LINE 1-fO7C7 C.1 'L- <br /> FOUNDATION _6 2Er AGRICULTURE WELL L.T OTHER WELL._ PITS/SUMPS N� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !/ <br /> C} Industn it ❑ Open Bottom D Manteca Dia. of Wet! Excavation �' Dia. of Well Casing o' <br /> Type G <br /> C7 Domestic/Private Gravel Pack r T Tracy YP of Casing Specifications3-� �"y- Wl <br /> ['1 Public M Other (1 Delta Depth of Grout Seal 3f0 16 Type of Grout C Mzar <br /> �A rox. Depth I 1 Eastern Surface Seul Installed by 'Plyl'i"f2 T <br /> I I IrfiDation L� pP P <br /> Repair Work Done 0 Type of Pump +�� . — H.P. State Work Done <br /> Well Destruction © Well Diameter � Sealing Material & Depth . <br /> Depth Filler-Material & Depth <br /> TYPE OF SEPTIC: WORK: NEW INSTALLATION [ I REPAIR/ADDITION l I DESTRUCTION I I avails ptic system <br /> m re200 nted if public sewer is <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" ❑ Type/Mfg Capacity No. Compartments . <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well.— Foundation Property Line <br /> LEACHING LIN_E ❑ No. & Length of lines ,Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 taws, 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 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 alifornia." <br /> The appli antJmustFall f II req inspections.r �omplete drawing on arse soar` <br /> Signed .� v Title: �r- '` - Date: 3� <br /> j FOR DEPARTMENT USE ON t&3% <br /> Application Acc <br /> SA 19A Data S �� Area <br /> ENVIRON t' <br /> Pit or Grout Inspection L ante Final Inspection by Date <br /> Additional Comments: SPI JA TT <br /> AppliceA - Return 8.11 copies to: San Joaquin County Public Health <br /> Services, Environmenta;. Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 BOX 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMtTTED C:S.j RECEIVED By DATE PERMIT"No. " <br /> INFO CASH <br /> EN 13-24 MEV.h/MSS ��..- C ; - <br /> EN:4.211 <br />