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a <br /> s <br /> p' <br /> NEW <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HALELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for a permit to construct .end/or install the work herein described. This <br /> application is made In compliance with San Joaquin County Ordinance Ro• 549 and I862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address � l! ? r� / Crtyx- Lot Size/Acreage .s-{ <br /> Owner's Name E P� -r< I I-C! Address � �,`7 i ? /nj V I�_ Phone 3�- 7 ar <br /> I <br /> conaar.to •- l0 {'/a,<+ d Pau"ess.—� r� �ptJ� ;/-� f [� n <br /> _License No. 3y��Phone X - V~ <br /> TYPE OF WELL/PUMP. NEW WELL q'i, WELL REPLACEMENT 7, DES IrRUCT10N Out or Service 4e11 <br /> PUMP INSTALLATION X SYSTEM REPAIR 2 OTHER D Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL _ PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM ARFA CONSTRUCT DN SPECIFICATIONS <br /> fl Industrul Cl Open Bottom C s Manteca Du. of Well Excavatan, �— Dia.of Wolf Catirp � <br /> kDomestic/Prrvste Gf"Pack () Tracy Type of Casing Specifications <br /> Specifications <br /> I'!Public / 1 gPar r'l Delta Depth of Grout Seal _ j(�� t Type of Grout <br /> 114"IJ41ron Approa, Ot>ih I I Eastern Surface Soul Installed by re•� <br /> } Repair Work Done 0 Type of Pump 4[jbe, If P,—3 Stam Work Done_ O <br /> Will Destruction D Well Diameter t/ealing Meterlsl g Depth <br /> Depth Tiller Material i Depth -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permittetl it parDlie saywr is <br /> available within 200 feet.) <br /> initatlation will serve: Residence_ Commercial_ Other <br /> Number of living units:_ Number of bedrooms_ <br /> Character of soil to a depth of 3 font: Water,tabla depth <br /> SEPTIC TANK O Type/Mfg _ Capacity No.CompartmentsPKC. TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line_ <br /> 1 <br /> a L"CACHING LINE Ll No.8 Length of lines Total length/size y„ <br /> FILTER ZED C) Distance to nearest: Well Foundation Property line U <br /> f SEGP.-kGE PITS I ! Depth Silo <br /> Number <br /> SUMPS LI Distance to nearest: Wall __ Foundation Property <br /> DIS?OSAL PONDS L0 Line s <br /> I hereby tert0y that I have prepared this s e1 <br /> X ppllcation and th.t tre work will be done in acco(,Mnce with San Joaquin county ordinances,stab laws,and <br /> 1: rulea and regulations of the San Joaquin County ? <br /> Home owner or licensed agent's signature certifies the followin I certifythat in the rformin,:e of the work for which this `4 <br /> emp17 an g' pe permit is leveed,I shat,not <br /> Y y person.in such manner as to bay cme subject to workman's compensation laws of Coli!ornls."Contractor's hiring or outrcr7ntracting signature <br /> tach las t e f Cali or p,I certify that in the perform once of fheo n nrk for which this permit is issued,I shall employ persona subject to workman's componse. <br /> tion The app=icsnttoll for all regwred inspecC ns. Cemplefe don reverse side. <br /> Signed �'� -�LJy_ 4"'�� _ Q <br /> ties r r Date: Z / <br /> _ F T USE ONLY <br /> Application Accepted by <br /> _ w4 <br /> Date 2�— <br /> ::!or <br /> Grout ntpectlon b DatrXI Final Inspection by > Date`r <br /> Additional con„�vnts: <br /> Applicant - Return all ecpiea to: Ban Joaquin County Public health <br /> Services, Fnvironaental Health Persalt/Services <br /> 1601 S. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED aV <br /> INFO ASR DATE PERMITNO. <br /> • EN 1774101tv.,reei <br /> • j la:a.7a �� ,ons 4 , od `fu7 � �', ..� J o- ?�l :;; <br /> I <br />