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l <br /> APPLICATION FOR PERMIT <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 /> P KUIT EXPIRES 1„ YEAR FROM DATE . ISSUED <br /> (Complete is 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. <br /> d� \ Cit Lot Size/Acreage <br /> Job Address Y" <br /> Owner's Name Xddress 1-PAz:, t_- -- Phone( U <br /> za <br /> 7 <br /> Contractor pr�/� Address �9' 3t `rL�L'!rd License"Nov���KzF 7 Phone . <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E_l DESTRUCTION XOut of Service well ❑ <br /> PUMP INSTALLATION 13SYSTEM REPAIR 0OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLO. PROP. LINE <br /> FOUNDATION --____— — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> 0 Industrial ❑ Open Bottom ❑ Manteca__ Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> F.I Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public I'1 Other n Delta Depth of Grout Seal Type of Grout' <br /> „ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P; State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION a( (No septic system permitted if public sewer is <br /> available within 200 leet.) <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 t <br /> SEPTIC TANK 0 type/Mfg t Capacity 20 a�� No. Compartments <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal <br /> Distance to nearest: Well /on.� ,Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ^ . / Jr�14 P_ _� Total length/size + <br /> FILTER BED 171 Distance to nearest: :Well Foundation Propeny Line <br /> SEEPAGE PITS ti Depth Size Number <br /> SUMPS E1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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"parformance 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 signaturq <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 /> lion laws of California." <br /> 0 <br /> The applicant must call forall ire 'nspections. Complete drawing onn reverse side. <br /> "Signed X Title: " 2;7 Ll n lLltt lrDate: 0 <br /> t O EPARTMENT USE ONLY <br /> Application Accepted by011"k IfAMA. <br /> "- —Dat - Area 0 <br /> Pit or Grout Inspection by Date Final Inspection by Datewo <br /> Additional Comments: yArter—A CW <br /> Applicant — Return all copies to: San Joaquin County blit Health <br /> 4 <br /> i Services, Fnvirpnai6ntal Health"Permit/Services <br /> k. <br /> 16011 Hazelton Ave... P 0 Box 2009, Stockton, CA 95201 <br /> IME AMOUNT DUE OUNT REMITTED CASH RECEIVED BY' DATE PERMIT'N0. <br /> + EH 6.24 IREV,1ie31 <br /> EH 74.26 !' • t!� f-�� J" 'L O�v FAV (lY+"V" <br />