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I <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 /> SIT EXPIRES_1_YEARFRQbd.DATE ISS UED <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. 5h9 and 1862 and the Rules and Regulations.of San <br /> Joaquin County Public Health Services./ <br /> Joh Address ` � u �J �® City Loi. Size/Acreage J <br /> Owner's Name Address k30 i_0 J01AC_9; Phane <br /> Contractor fl ooi-,; WAITp�U'JWddress . P1D r�4u_J�7_ License No. dz Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION Pt SYSTEM REPAIR 0 OTHER ❑ Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK Ur2 ' SEWER LINES 1510 : DISPOSAL FLD. 1SIO PROP. LINE - <br /> Y-0-FOUNDATION . AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial - �Open Bottom D Manteca Dia. of Well ExcavaatioTn,- Dia. of Well Casing <br /> IX Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing CIA <br /> Specifications--- --1--Z w` <br /> I'] Public CI Other n Delta Depth of Grout Seal 5_01 ,� pp Type of Grour 'gf. A Lk 5A d <br /> I I irrigation ._._.Approx. Depth I ) Eastern Surface Seal Installed by Ghia ads, 4-If-1f j2e,11 1i 0 <br /> Repair Work Done L7 Type of Pump sir b H.P. � State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth 1 <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is J <br /> available within 200 feet.I <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:' ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE Cl No. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 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 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 t <br /> � call a all/re ired ins ctions. Complete drawing on reverse�e. <br /> Signed X Title: C42/f2 fgd <br /> E�d �j <br /> Date: 3 <br /> ` FOR DEPARTMENT USE ONLY q 1 <br /> Application Accepted by �1iV. Date_ [ Area <br /> Pit or t Inspection by Date_ Final Inspection by Date <br /> (( <br /> AdditionalComments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO <br /> FEE AMOUNT DVE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> EH 3 24 22-0 <br /> 3 <br /> IA ,EH {29Q :Es ala�d� <br />