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APPLICATION FOR PERMIT <br /> v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE) <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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. p 4 <br /> Job Adclfest;17� N, / City sem* ��� Lot Size/Acreage <br /> Owners Na-s � * F :1°laY6�Tirrnreys,�� Phone <br /> 'P"'Ctinhactor r'-"AddreiL152 7ffi - � -N 3"Phd ' <br /> TYPE OF WELL/,PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well Ci <br /> PUMP INSTALLATION 0 SYSTEM'REPAIR Cl + M OTHER 0 Monitoring'Well 0 <br /> DISTANCE TO NEAREST> SEPTIC TANK SEWER LINES . v � DISPOSAL FLD�. PROP. LINE _I <br /> i _�—EOUNOATION_ a - AG IR CULTURE WELL OTHER WELL PITS/SUMPS, <br /> INTENDED USE TYPE OF•W�ELL �PROSLEfN ARIA CONSTRUCTION SPECIFICATIONS y ( <br /> n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casir i <br /> C.1 Oomesticl Private 0 Gravel Pack 0 Tracy Type of Casing Specifications E i <br /> I'1 Public 0 Other 0 Delta Depth of Grout Seal Type of Grout <br /> I I Nrigation _Approx. Depth I I Eastern i Surface Seul Installed by ' 1 <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sailing Material & Depth <br /> Depth Fiiler Material & Depth \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted-if• public sower is O available within 200 lest.) <br /> Installation will serve: Residence_ Commercial X., wilher <br /> Number of living units: t A Number of bedrooms <br /> Character of Will to a depth of 3 feet: Water table depth' n ON I j <br /> SEPTIC TANK Ayjm.—O Type/Mfg } Capacity^ No. Compartments <br /> PKG. TREATMENT PLT. L —J Method of Disposal <br /> Distance to nearest: Well Foundation - Property Line o e, E <br /> I f ♦ i <br /> LEACHING LINE ,.[ r�u 11 r i <br /> ;X+� No. & length of lines ��IY �� notal length/size r I — �� ♦ 7r•,. >_1 \, <br /> `FILTER BED 0 Distance to nearest: Wellhk!V46� Foundation r,10 Property line <br /> i i 1 <br /> SEEPAGE PITS . Depth site - — Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I herebyCerlif that 1 have prepared t ` } <br /> Y p pared this application and that the work will be done in accordance with San Joaquin county ortlinances,state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies the foaowing:;'I certify that in the performance of the work for which this parmit is issued, I shall not <br /> employ an <br /> y person in such manner as to become subject to workman's compensation Wwa of California."Clili "Contractors hiring or sLbScontracling signature <br /> certifies the following:"i certify that iri the performance of the work for which this permit is issued.I stall employ persons subject to workmah's compensa• <br /> tion laws of California." = m , <br /> The,applicant must call for all raqui d in coons(Co,Plpate dre{wing''!verse side. <br /> Sign!� Tina: f?O/1r r Date: <br /> DEPARTMENT USE ONLY <br /> APPj,icetion Accepted DY y �A,EA4 Date Area <br /> Pit or Grout Inspection by Date f _Finel_IpspeciionbY S5fk Date <br /> Additional Comments: <br /> • ApPiicent - Retura all ..pies to: San Joaquin County Public Health <br /> Services, Ravironmental Health Permit/Services <br /> 1601 8. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 yv,` <br /> N O AMOVNT DtlE AMOUNT REMITTED CASH _ RECEIVED By DATE PERMIT NO.EH 3-24 <br /> 1 y <br /> EH 9a7a IAEV. <br /> 4 <br />