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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SIPVVICTS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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. <br /> Job Address 2_-5 4 Nor-t-A LQ n City Lot Size/Acreage <br /> T n <br /> _5 , e Address �7/0 4C9 ` Q� h ( O <br /> Owner's NameChevron VMine ' QM�rhone <br /> 1 -94,59 <br /> 11 z - HA247.fr/�pjw vG x-33 ertl , o Co oyQ C 57 y7 4 <br /> Contractor(11+001 (SeGSQP_hCf_ _ Address L000 /3 r NL G�Yd License No.p.6-50'S9 Phone .d J58 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT _ ESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYS EM REP9IR ❑ OTHERX Monitoring Well ❑ <br /> DISTANCE TO N AREST: SEPTIC TANK ~ SEWER LINES 30 DISPOSAL FLD. PROP. LINE 7�5 <br /> FOUNDATION �f O / AGRICULTURE WELL OTHER WELL — PITS/SUMPS_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F.1 Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> 11 Public n Other F1 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 U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameser Sealing Material i Depth <br /> X7'pepthFiller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 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 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Me�}1p{c�pieta► <br /> P Y <br /> Distance to nearest: Well Foundation Pro ert <br /> LEACHING LINE ❑ No. & Length of lines Total length/siz 1199-2 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pro% 156 <br /> J/�+tV Cv_ TY <br /> SEEPAGE PITS 11 Depth Size NumtW r - DWISION <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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: "1 certify that in the performance of the work for which this permit is issued, 1 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 California." <br /> The applicant MY,; .Mimcl inspections. Complete drawing on reverse side.. . <br /> Signed X T'tle: � � 6-00144 15,k Date: 1 <br /> Vf 2— <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date e <br /> Pit or Grout Inspection by a Final Inspection by Date � Z <br /> Additional Comments: !� <br /> Applicant - Return all copies to: San Joaquin County Public Health //1 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> r <br /> INFO AMOOU�NIT DUE AMOUNT REMITTED CK CASH RECEIVED BY OATE PERMIT'N0. <br /> • EH 13-24(REV.1/0151 Y' lL- f <br /> EH:4.211 �O/ <br />