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.. i4 i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENNTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> r <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> pf" T WIRES1 YTsAR FM DATEISSUE <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 />'E application Lie 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 /> :94f rci_ 'F-Scat Ir­) Lot Size/Acreage •s^ <br /> Job Address ` v _ City, <br /> Dc�n elS <br />'I Owner's Name + Address 19 4 Phone. <br /> ��oht 3183 <br /> ContractorFOIA t�Xce�' C Address q*250i � S _License lvo. 622130 Phone�lD QqQ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER�S�jitvw 1 ^Ci7pe SSS <br /> 1 _ DISTANCE TO NEAREST: SEPTIC TANK 1Ati 1---.SEWER LINES _ 50 - DISPOSAL FLD.N_ PROP. LINE D leho <br /> FOUNDATION 4d► ._"AGRICULTURE WELL 9D—i OTHER WELL PITSISUMPS 1&k2f �S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private 10 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> VI Public !JX Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation 7o �__Approx. Depth M'Eastern Surface Seat Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ Q <br /> t <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth \ - <br /> . Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> _ available within 200 feet.) <br /> r - <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 tapbl <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Curape s� <br /> PKG. TREATMENT PLT. ❑ MethRrg10 <br /> ? Distance to nearest: Well Foundation Property Li <br /> rrr- 92 <br /> LEACHING LINE C1 No. & Length of lines Total length/siz TT 1O�AQ( '. <br /> FILTER BED ❑ Distance to nearest: Well Foundation PropeTH DfV'tS+J'`' <br /> trNVIH0 <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <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 <br /> ountyHome 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 taws 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 /> i tion laws of California." <br /> t The applicarhnusil call for all r wired inspections. Complete drawing on reverse side. <br /> Signed Title: T_T_Mi j adl— ate: 2. �Z <br /> FOR DEPARTMENT USE ONLY �� O <br /> Application Accepted by Date <br /> I "~Pit or Grout Inspection by ` �%i ate Final Inspection by <br /> Additional Comments. <br /> Applicant - Return &.1.1 copies to: Ban Joaquin County Public Health <br /> Services. Environmental Health Permit/Services <br /> 1601 X. Hazelton Ave.. P 0 Box 2009. Stockton. CA 95201 <br /> FEE AMOUNT DUEAMOUNT REMITTED SASH RECEIVED BY DATE PERMiT'N0. r �� <br /> INFO /►� <br /> . EH 13-74 IREV.ri n si (8q• 06) ^gq'oo <br /> EH 141e <br />