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9 <br />APPLICATION tr <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SICES <br />ENVIRONMENTAL TH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />e 1 <br />P O BOX 2009, STOCKTON, CA 95201; <br />PERMIT EXP I RES 1 E FROM DATE ISSUED S <br />(Complete in Triplicate) r`yRa��E <br />Application is hereby made to San Joaquin Bounty for a permit to construct and/or install the work kerein 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=M011h. <br />Ails <br />City _J..0_d7 s r AtlotiAltEt4re1$e CCE, <br />fi 0 . Ela <br />1810 E. Hazelton Ave. <br />..OwfJ SaJ0�9IifSifl <br />! CA,,..,9 U111 Hilt) Il:to ne 9)468-3066.; <br />�_r ie d <br />,Apdf„S gr <br />633wfr} Rd a ,, <br />0 <br />llf� ri <br />IeAS SCA°g95 X36 Phditc{9l6 x71022 <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION t of Service Well ❑ <br />PUMP INSTALLATION O �YSTEM REPAIR O OTHER O Monitoring Well 9 <br />DISTANC � REST: SEPTI TANK <br />SEWER S , DISPOSAL FLD,” r PA N9 N'� <br />� ' <br />o <br />N A <br />'� AGAICULT ELLh HER LLQ ��s IIT AMPS601 <br />INTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />(l industrial <br />❑ Open Bottom <br />O Manteca Dia. of Well Excavation Dia. of Well Casing <br />( I Domestic/ Private <br />❑ Gravel Pack7 <br />D Tracy Type of Casing_ Specifications - <br />1'1 Public <br />Ia Other <br />Fl Delta Depth of Grout Seal Type of Grout <br />I I Irrigation <br />— Approx. Depth <br />11 Eastern Surface Seal Installed by <br />Repair Work Done U <br />Type of Pump <br />H. P. State Work Done _ <br />ell Destruction <br />Slf�T ling terial 6 Depth 9 Bark rn13 t, _ 11rry <br />rql is <br />115 'q(Vap " 40t <br />to <br />Filler Material L Depth <br />T OF SEPTIC WORK: <br />NEW INSTALLATION I I REPAIR/ADDITION 1 ) DESTRUCTION I 1 (No septic system permitted if public sews ' <br />available within 200 feet.) <br />Installation will serve: a Commercial — Other <br />Number of living units: Numb�rooms <br />Character of soil to a depth of 3 feet: star table depth <br />SEPTIC TANK O Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. ❑ Method of Disposal <br />Distance to nearest: Well datio Property Line <br />LEACHING LINE ❑ No. 6 Length of lines Total /size <br />FILTER BED 13- Distance to near Wali Foundation Props s <br />SEEPAGE PITS Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation -'Property Line <br />DIS L PONDS O <br />hereby card y 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 must call for all required inspections. Complete drawing on reverse side. <br />U FOR DEPARTMENT USE ONLY '�v'1'�'"' <br />Application Accepted by ok <br />Date _ _l 1 Area % <br />Pit or Grout Inspection by DZ_ —ate Final Inspection by - std Date L �/ <br />Additional Comments: <br />Applicant - Return all copies to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N San Joaquin, P O Box 20og, Stkn, CA 95201 <br />- EH 13-24 (REV. rie5 <br />EH 1446 <br />FEE <br />I- <br />AMOUNT DUE AMOUNT REMITTED <br />CASH <br />IINFO RECEIVED 8Y <br />bATE <br />PERMIT' NO. <br />Wh®•®® <br />Cos.°® <br />o <br />