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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> I P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIX EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to SanJoaquinCounty for a permit to construct and/or install the work herein described. This <br /> application is made in cotnpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �y+y�� r <br /> Job Address _ _ a' Aoir _ City �7 �Qe/'-� Lot .Size/Acreage <br /> Owner's Name _ .� ­4 Address J/Y {, <br /> Phone <br /> r.ra <br /> Contractor jt.� Address License No. Aslf'tionet # - •;tj <br /> TYPE OF WELL/PUMP: NEW WELL 0. WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service..Well 0 <br /> PUMP,INSTALL'ATION-0 ° �SYSTEM REPAIR M OTHER C Monitoring Well 0 <br /> DISTANCE TO NEAREST:IS�TIC�TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> �.f i1FOUNDATf0N AGRICULTURE WELL t <br /> OTHER WELL PITS/SUMPS _ <br /> INTENDED,USE X^ItTTYPE OF WELL , PROBLEM AREACONSTRUCTION:SPECIFICATIONS <br /> n Industrial I"" D-dpen Bottom".0 Manteca Dia. of Weft Excavation Dia. of Well Casing w <br /> C.] DomesticlPrivate I Cl Gravel Pack C Trac Type of Casing r <br /> �f �Ly, yP g Specifications <br /> I'I Public �� CIOther i1 Delta` Depth of Grout Seal Type of Grout <br /> I <br /> Irrigation 1 <br /> g' ; Depth I I Easternt 4 Surface Seal Installed by <br /> Approk. <br /> / c+ - <br /> Rapair WoWDIt ne L7.-„.Type-of Pump H.P. State Work Done _ <br /> Well-Destruction �O Well Diameter Seshng,Material & Depth <br /> 1 Depth Filler,Material & Depth IV <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONJK DESTRUCTION I I (No septic system permitted it public sewer is <br /> 1. available within 200 feet.I <br /> Installation will serve.-.Residence- Commercial­.Other h <br /> Number of living units: Number of bedrooms <br /> Character of soil to a d pth of 3 feet: 4 4 r Water table depth <br /> SEPTIC TANK- 1 TypelMfg Capacity� T No, Compartments <br /> PKG. TREATMENT PLT, 0 Methodof Disposal <br /> Distance to nearest: Well •G ��/ I <br /> s � � Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines �` Total length/size o <br /> FILTER BED C1 Distance to nearest: WellI—. :�-4 .1 <br /> Foundation Property Line <br /> r <br /> SEEPAGE PITS }� 11 Depth _ /3 r Size '"*"� Number <br /> SUMPS ! ��` <br /> l�Y Distance to nearest: WellA2 Foundation `tfod, Property Line_fs ------ <br /> DISPOSAL PONDS EI s # <br /> I hereby certify that I have prepared this application-end 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 t <br /> Home owner or licensed agents signature certifies the following: "I certify that n the performance of the work for which this permit is issued, I shall not i <br /> employ any person in such manner as to become subject to workman's compensation laws of California.” Contractor's hiring or subcontracting 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 mu all for all uir d inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title Date: V- (Q <br /> " <br /> OR-• EPARTMENT USE ONLY �� 1 <br /> Application Accepted by Date -C�v la�res <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> I <br /> Additional Comments: i <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 /> FEE A OUNT DUE AMOUNT <br /> INFO REMITTED <br /> RECEIVED BY DATE_ PERMIT'NO. <br /> EH 13-24 IREV.t n 51 <br /> EH s4-26 <br />