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a <br /> �I APPLICATION ICOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION C <br /> I) 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 PAYMENT <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> RECEIVED <br /> PEMIJ EXPIRES ] YEAR FRPM PAIA ISSUSD MAY 2 0 <br /> �) (Complete in Triplicate) <br /> SN COUNTY <br /> Application is hereby made to ,San Joaquin County for a permit to construct and/or install th iil5 }c � This <br /> " ,. <br /> application is made in cotliaitce with San Joaquin County Ordinance No. 51+9 and 1862 and th� <br /> Public Health Services. ENV <br /> M <br /> Joaquin County A <br /> Job Addresst�fltSrfM1� City Lot Size/Acreage <br /> Phone a <br /> YCb `L <br /> Owner's Name u51� Address <br /> Contractor I� Address d v �yr �KS1�Qf�Vf+ License No, h ! PhoneIV <br /> 0 00 9 i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ { <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 5101"/60THER „ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3,/4 T� ft-(SW 2D' i� <br /> C-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 Dia. of Well Casing <br /> El Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing r Specifications // <br /> f'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout 6151 t <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done <br /> I �J <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth li Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> ii available within 200 feet.l <br /> Installation will serve: Residence II Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth.of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ it Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I� <br /> LEACHING LINE D No. &`Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> IN <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distan.ice to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ h <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 /> Home owner or licensed agent's signature certifies the following: "1 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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of Californi ;I <br /> The applicant mus for all required inspections. Complete drawing on(reverse <br /> Jside. <br /> � <br /> Signed Title: - Y�rf'\G�AGDFF� _ Date: <br /> FOR DEPARTMENT USE ONLY f <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection by �I Date Final Inspection by Dater <br /> Additional Comments: II <br /> Applicant – Return all copiesl�to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> f-EE AMOUNT DVE AMOUNT REMITTED CK RE E ED BY DATE PERMIT'NO. <br /> INFO CASH <br />. <br /> EM t]7<IREV.rin5t ,I '�O <br /> EH 541-2s VVV 1 <br /> �I <br />