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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ,. pEuJtTm EXPIRM 1 EAR PROi� RATE ],� S5 �UE1a <br /> (Complete in Triplicate) <br /> ! <br /> Application in hereby made.to San Voaquin County for a permit to construct and/or instar.!.! the work herein described. This <br /> application is made in coopliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic e. <br /> r <br /> Job Addresls .....�._. <br /> t Ci? Lot Silt!/Acreage q <br /> Owners Name �� ✓-Add"redsr ' <br /> e Na, Phone �J <br /> r_� i.. r .—..-_—�•- �...�'� .'" "`� Phone r �,ii ..3 ��•.. <br /> Ltonfiactwi6­40 � ,_.� Address l-•�..j _Licens <br /> TYPE OF WELLIPUMP .v NEW ELL 0 \EELL REPLACEMENT'n DESTRUCTION 0 Out of Service Weil. Cl <br /> PUMP INSTALLATION O YSTEM AIR-Cry �' OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER DISPOSAL I LD.� PROP. LINE <br /> FDLINDATiDN AGRICUE LL OTHER WELVL PITSISUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS <br /> Industrial + ©Opan'Bbttam--- C M,antaca u a. of Well Excavation -- — Dia. of Well Casing <br /> ;.i Domestic/Private CI Gravel Pack G Tracv YET Per <br /> 'of Casing—_ i Specifications <br /> I". Public 1, Other 1`I Delta D pth of Grout Seat Type of Grout <br /> Irrigation I _.Apprott. Depth I 1 East S rlaice Seal installed by <br /> Repair Work Done )' 0 Type of Pump H.P. + State Work Done - -`J <br /> Well Destruction 1 0 Well Diameter Selling Material A Deyth4 <br /> Depth Filler Materi i Depth - �^ <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION I I REPAIRIADOiTION DESTRUCTION i I (No septic.,iystem-permitted iI blic Sawa is �} <br /> r tl available Within 200'9e i <br /> !notoria?ion will serve: Residence" Commercial_ _ Other 0•, ` I <br /> Number of !;vino units: Number of badrao _._.�__ <br /> Character of soil to a depth of 3 feet: 1 W at <br /> SEPTIC TANK. 0 Type/Mfg ' Capecit No. Compartments 1 <br /> PKG, TREATMENT PLT.0 Method`of"D*-"Sl <br /> / Distance to nearest: felFoundsti Property Line + <br /> LEACHING LINE Ll No. b length of lines Toi�al�lengthlsixe 'v N\ <br /> FILTER BED n Distance to nearest; Well_ �! _Property Line <br /> SEEPAGE PITS 1 I^ Depth L. — size umber - 1 <br /> SUMPS LI Distance to rissfW: Wallountlation. Properly Line <br /> DISPOSAL PONDS 11 <br /> I hereby certify that I have prepared this,application and that the work will be done In accordanca with San Joaquin county ordinances, state laws, and`'+ <br /> rules and regulations of the San Joaquin;County "-- <br /> Nome owner or licensed agent's signature certifies the following: "I certify that in the performance of file work for-which this permit is issued, I shall not� <br /> errmploy any person in such mannsr_it to`becoma subject to workman's compensation laws of California."Coitractor's hiring or sub-contracting signature <br /> certifies the fokowing:"I canify that in the pertomiartce of.the work for which this permit is issued.1 shalt employ persona subject to workman"*carnpensa- <br /> tion laws of California." <br /> The applicant) st C311 f toqiimill i spections. Complete drawing on reverse side: <br /> Signed X. _ Title: -� C ✓ti�" f , --.` f�Xta: J j <br /> .DEPARTAIIENT USE ONLY ^� �✓ 1 <br /> �i/ <br /> Applicaron Accepted by Data `Area c _y <br /> Pk or Grout inapection by ata .F;na1.1 p 'on y Data`-� <br /> Additio-wi Comments: <br /> Applicant - Return all copies to: San-Joaquin County Public Health ..j <br /> Services,.Davirodwntal Health Permit/Services <br /> 1601 E. Aattiton•-Ave., P 0 Sot 2009, Stockton, CA 95201 <br /> INFLS AMOUNT DUE � AMOUNT REMITTED CA5 RECEIVED 9Y DATE PERMIT NO. <br /> . EH <br /> 13-24 IMEv.r)a+s� <br />