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APPLICATION FOR PERMIT n A" <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PEIT EXPIRES 1 YEAR FROM DATE. SUED <br /> �( R (Complete iu Triplicate) <br /> Application is hereby made to S Quin County for a permit to construct and/or install the work herein described. This <br /> application Is trade in compliance with San Joaquin County Ordinance No. 549 and2 and the Rules and Regulations of San <br /> L3N <br /> Joaquin County Public Health Services. OPAff P,fl� ;i-,1 5u1510 �APfI 089^0r.7,G—gq c a5 <br /> Job Address 4L0Ei S77t1,u City Lot Size/Acreage <br /> Owner's Name 14096I?2'-d 409L/�x�Address 18 130K. A90YE36 4 Phone <br /> Contracto Cly Address 25 my 5 License No,S]Z _6$ Phone RYG-13M <br /> TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION D Out-.of Service well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER'$ Sr d -dam_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ZOr P� <br /> ED Industrial 0 Open Bottom 0 Manteca Dia. of Wel! Excavation Don of <br /> Ci Domestic/Private 0 Gravel Pack C7 Tracy Type of Casing 1-4 LL <br /> I'I Public 0 Other 1-1 Delta Depth of Grout Seal Type vL-Grout $ �- <br /> I I Irrigation _.•. Approx, Depth I I Eastern Surface Seal Installed by rr t C{ rr <br /> Repair Work Done L7 Type of Pump H.P. State Work Done df -M <br /> Well Destruction 0 Well Diameter Sealing Material Depth <br /> Depth Filler Material fr Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: - Number of bedrooms V <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. 0 Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number YP <br /> SUMPS CI Distance to nearest: Well Foundation Property Line �` p <br /> DISPOSAL PONDS 0 <br /> I <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 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 orsub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> I <br /> The applicant must call for all re d inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: PJ 5 Hate: _F3 Z_""!b <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by Date FOArea f <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Oats 47 <d. <br /> 1 <br /> Additions! Comments: �i"CtL>/r' 7�p-y;'� f", <br /> Applicant - Return all copies to: San Joe uin County Public Health <br /> Services, &virontttental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO C��ASH RECEIVED BY DATE PERMIT'N0. <br /> • EH -208 IREY.I/n 51 <br /> A <br />