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q 0-� <br /> APPLICATION FOR PERMIT <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i EXP RES 1 YEAR FROM D TE ED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance;with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> .f � e <br /> ob Address D 1 City Lot Size/Acreage — <br /> s I t <br /> < �! t t C,CSAddress �( m ETT Z— ..�--- Phone <br /> Owner ZS� <br /> 's Name t E I <br /> r <br /> ,i 5L L Address License No._ _�—Phone <br /> Contractor F t af;Serylce Well <br /> WELL REPLACEMENTY❑..,,�,„,.,.,�,FDEST.ROCTION,CI-Du. - <br /> TYPE OF WELL/PUMP: NEW WELL,❑ _ OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ x SYSTEM REPAIR ❑ - _ <br /> ' i = IC r . "`-DISPOSAL FLU. 'PROP.".LINE. <br /> '- -0l$TANCE T0'NEAREST:-SEPTTAI�V1< EWER LINES' <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PIT5/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia o�,Well Casing <br /> 0 Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Specifications <br /> 11 Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing <br /> I 1 Other n Delta Depth of Grout Seal Type of Grout <br /> I"I Public , <br /> I I Irrigation —,Approx; Depth l I Eastern Surface Seal Installed by <br /> H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump 1 <br /> Sealing Material & Depth <br /> [3 <br /> Well Destruction Well Diameter Filler Materiel 5 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I iNosblei cyst m permfee itted if public sewer is <br /> avaInstallation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal . <br /> Distance to nearest:, Well Foundation Property Line _ \ <br /> LEACHING LINE ❑ No. & Length of lines -7WTotal length/size <br /> FILTER BED ❑ Distance to nearest ll w r Foundation _� Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> j SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> !l DISPOSAL PONDS ❑ <br /> I hereby certify 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 /> f 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." e <br /> The applicant gustall for all r ired ins ctions. Complete drawing on reverrse�side. <br /> Signed X e % "` Title: Date: �J— <br /> ODEPA D1T'-USE ONLY q <br /> ti- l �) _ Area <br /> by Date <br /> Application Accepted -- <br /> Pit or Grout Inspection by Date Final Inspection by� <br /> Additional Comments: , <br /> I Applicant - Return all copies to: "San Joaquin County Public Health <br /> - a- Services, Fnvironmental•Health Permit/Services <br /> i601 E. Haselton Ave., F O,Box 2009, Stockton, CA 95201 <br /> M ffE7 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> k AMOUNT =i AMOUNT RATTED CASH cr <br /> .• EN 13-24 IriEV.r n 51 <br /> V d ... - ?V .J <br /> 1 EH;4•Ie . <br />