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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 0 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> Z MIT MIRES 1 YEAR FROM DATE ISSUED(Complete in Triplicate) <br /> Application is hereby made to San Joaquin County f <br /> application is Lands in compliance with San Joaquin or a Permit to co¢atruct and/or install the work herein described. This <br /> County ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County{/P�ublicj Health Service /. � `-}� S-/7� <br /> Job Address CA z ,n" ` &q� o `�`"'� t Z� City 9> y) Wt Size/Acreage <br /> Owner's Nameu Y^S ` Address -..J C--M e- - ��.3 <br /> /7 1� } L n Phone <br /> / _ C.YI XJ2 , X - Address �U e�-a-( �o <br /> Contractor License No.0I 33�sh2-Service <br /> 'I2S <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Nell ❑ <br /> -� PUMP INSTALLATION ❑, _ SYSTEM REPAIR ❑ OTHER O Monitoring Nell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL.FLD. PROP. LINE - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Die- of Well Excavation Dia. of Well Casing <br /> O Domestic/Private _❑ Gravel Pack ❑ Tracy - Type of CasingS <br /> I'1 Publip pecifications <br /> f 1 Other n- Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Apprax. Depth I Eastern Surface Seal installed by - r <br /> Repair Work Done U Type of Pump --w H.P. -- State Work Done_ `) <br /> Well Destruction -*p Well Diameter. Sealing Material i Depth <br /> w <br /> Depth Filler'Material 6 Depth <br /> IC <br /> TYPE OF SEPTWORK: NEW INSTALLATION I I-MrAIR/ADDITION IV DESTRUCTION I I INo septic system permitted if.public sewer is <br /> T, <br /> Installation will serve: Residence_,Commercial' Other available within 200 feet.) W <br /> Number of living units: _ Number of bedrpo _ Ire <br /> Character of soil to a depth of 3 fast: i 1 ) /-,X, <br /> SEPTIC TANK. Water table depth 4._ <br /> O Type/Mfg Capacity No. Co r <br /> PKG. TREATMENT PLT. ❑ t mpartments -'�� - <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines - _ Total length/size <br /> FILTER BED C] Distance to nearest: WeII Foundation <br /> ., Property Line (r' <br /> SEEPAGE PITS #I Depth Size <br /> SUMPSNumber <br /> ' <br /> CI Distance to nearest: Well Foundation 1'` <br /> DISPOSAL PONDS 11 - -- _ - Property Line <br /> s_ <br /> I hereby certify that I Neve prepared this application and that Lh <br /> rules and regulations of the San Joaquin County -a work will be done in accordance with San Joaquin county Ordinances, state laws, and <br /> - _ <br /> Home Owner licensed agent's signature certifies tits following; "I certify that in the perlormance of the work for which this permit M issued, I shall not <br /> certifies the following: <br /> any person in such manner as to become subject to workman's compensation lawn of California." Contractor's hiring w sub-contracting signature <br /> "I certify that in the performance of the work for which this Permit is issued;1 shall-employ persona subject to workman's compensa. <br /> tion laws of California.^ <br /> The applicant must pall for aq r inspections Complete drawing an reverse <br /> side. <br /> Sign _ Title: Date: 91 <br /> ----L <br /> OR gEPARTMENT USE ONL'Y�ri� <br /> Application Accepted by B <br /> Date Area l . <br /> Pit or Grout Inspection by Data Final Inspection by <br /> Date <br /> Additional Comments: j <br /> Applicant - Return all copies to: San Joaquin County Public Health 3 <br /> "- •- " Services, Environmental Health Permlt/Services- - -13, - - - <br /> 1601 E. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 - �— <br /> FEEH_%A <br /> MOUNT DUE AMOUNT REMITTED,> CK _ <br /> INFO CASH ritECEIVED BY DATE PERMIT NO. <br /> ..-EH 13-24 IREV.vxe1 1. r� 11 c'� <br />