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4 <br /> I <br /> APPLICATION FOR PERMIT <br /> A J . <br /> O SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> .r' 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EMIRES 1- YEAR FROM DATE Ii$SUED ! <br /> i (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 it <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 /> I <br /> Job Address <br /> 2 4e CityLot Size/Acreage A C <br /> / r / <br /> Owner's Name U Z-A R & `fit'' Address Rk Phone <br /> Contractor�.11XL Ce-)ss. Address � License No:'k �� Phone3S <br /> TYPE OF WELL/PUMP: NEW WELL 9 1WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 19 SYSTEM REPAIR ON, n OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER TINES DISPOSAL FLD. PROP. LINE [St7 <br /> i <br /> FOUNDATION-�- - AGflICULTURE WELL.-= ---OT+HER-WELX-"'�PITSI-SUMPS- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> [1 Industrial ; O Open Bottom ❑ Manteca Dia- of Well Excavation_ I t Dia. of Well Casing <br /> 3Cd Domestic/Private `0 Gravel Pack ❑ Tracy Type of CasingAlG Specifications <br /> I'1 Public I-) Other .4 11 Delta Depth of Grout Seal Type of Grout_ <br /> c�`_.-:Aroe th t I Eastern Surface <br /> I i Irrigation 3 pp "k"DSeal installed by p <br /> Repair Work Done 0 Type of Pump it t w t H.P. °� <br /> State Work Done �_ <br /> Well Destruction ❑ Well Diameter ' Sealing Material & Depth <br /> Depth '� ; Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is <br /> available within 200 feet.] t <br /> Installation will serve: Residence 11 <br /> Commercial— Other <br /> Number of living units: Number of bedrooms (57 <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK. El "Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total Length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property line J <br /> SEEPAGE PITS i I Depth Size Number /h <br /> SUMPS LI Distance to nearest: Well Foundation . Property Line <br /> DISPOSAL PONDS ❑ t <br /> I hereby cenify•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.rhust call for all required insPections. Complete drawing on reverse side. <br /> Signed X �j��*•- Title: _41f Date: <br /> F DEPARTMENT USE ONLY ++ <br /> > `7 t�L Area 1 Z <br /> Application Accepted by /A w.. �aacng - Date <br /> Pit or rout speotion by "� -`�_._� Date - Final Inspection by_ Data- <br /> C� <br /> Additional Comments: <br /> Applicant - Return all copies 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. <br /> INFO 43. EN 13,24 IRM fIHSS /e5 L4�C - D �v —p O <br /> 0 <br /> EH 4.26 <br /> C, - <br />