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Y f Y <br /> APPLICATION- FOR PERMIT <br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 444 ENVIRONMENTAL HEALTH DIVISION <br /> . 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCgTON, CA 95201 <br /> ` EXP RES 1 YEAR FROM DA E <br /> r 'I (Complete in Triplicate) <br /> e to San Joaquin County for a permit to construct and/or install the work herein desionsdof Sano <br /> Application is hereby mad , <br /> application is made 1n complience with San Jpaquin County Ordinance No. 51+9 and 1862 and the Rules and Rego <br /> Joaquin County Public Health Services. ` [ I-sLU`d 1� Lot Size/Acreage <br /> t� <br /> �(o l0 k S . �w� \ City lr <br /> �b Address 1 Phone <br /> 8 1 <br /> p�n G. \t r` Address <br /> Owner's Name a N - r� r <br /> ` License No.�� Phone <br /> Address <br /> Contractor LL REPLACfMEN ❑ DESTRUCTION1 Out of Service Well ❑ <br /> NEW WE1�L ❑ OTHER ❑ Monitoring C7 <br /> TYPE OF WELLIPUMP: SYSTEM REP R 0 <br /> PUMP INSTALLATION © DISPOSAL FLO. PROP. LINE <br /> SEWER LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _.. � EL PITS/SUMPS <br /> AGRICULTURE WOTHER WELL�r--� , <br /> FOUNDATION I <br /> TYPE OF WELL a PROBLEM AREA CO RUCTION SPECIFICATIONS Dia. of Well Casing <br /> C T �—-- <br /> INTENDED USE { Di . o Well Excavation <br /> i C7 Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> ❑ Tracy ype o Casing Type of Grout <br /> C-1 Domestic/Private ❑ Gravel Pack n Delta Depth o Grout Seal - - <br /> I'l Public i:1 Other ` <br /> 1 Surface S al Installed by <br /> 1 i i Irrigation —.Approx. Depth I I Eastern H.P State Work Done <br /> Type of Pump 4-- <br /> 'Repair Work Done L7 Typ &ling Material Depth <br /> Well Destruction ❑ Well Diameter ��---- Filler Material & D th t <br /> G Depth t <br /> t <br /> t) eet.l .* ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlAOD.lTf6N available within 20I 1 IN. septic system (}ermined If pub Y c rawer is <br /> I � �- <br /> Installation will serve: Res'dence <br /> Comrr�ercial_.�.-'Other <br /> Number of faedroarns__,_X - t <br /> j Number of living units: Un Water table dl'7 <br /> 4 <br /> Character of soil to a depth of 3 feet: 2 co No-Nos <br /> � Type/Mfg .Llo..crt'>� Capacity --�` <br /> SEPTIC TANK. Method of Disposal <br /> PKG. TREATMENT PL7.'Cl` " h�~ Oo i <br /> Distance to nearZs . Well <br /> Foundation �A Property Line <br /> LEACHING LINE )5 No. & Length of lines <br /> Total length/size <br /> © 3o Property Line <br /> ( FILTER BED n Distance to nearestI: Well� Foundation _ <br /> I Size�- '� �'� Number_, <br /> l SEEPAGE PITS t>4 Depth <br /> I Distance to nearesti: Well- O Foundation 1_d-� Property Line Ll---. <br /> SUMPS j <br /> 01 L PONDS D <br /> I hereby certify that I have prepared this applicati n and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County g: <br /> Home owner or licensed�mannegn tuareb9ortiffi ubjec�Ito w1orkman'srtcompensation lawsoof California." Contractowork for rs hiring g or sub-contracthis permit is tinglsignatushall re <br /> employ any person <br /> f <br /> certifies the following: u certify that s the pertor encs of the work for which this permit is issued, I shall employ persons subject to workman's compen - <br /> il <br /> tion laws of California." <br /> I The applica t must call for �requved <br /> inspection Complete drawing on reverse side. <br /> �I� Title: _rte Date: <br /> V�Signed X <br /> OR PARTMENT USEONLY <br /> Area <br /> I y m Date <br /> I Application Accepted by_ Date <br /> Pit or Grout Inspection by <br /> Date�.----- Fine1 Inspection by <br /> P Additional Comments: <br /> ' Applicant - Return all copies to: Sen Joaquin County Public Health w. <br /> .. <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED BY GATE PERMIT NO._ <br /> FEE LINT DUE AMOUNT REMITTED CASH <br /> IN - - - ��_Cr b_6 J Z <br /> . EHt3-241REV.��KS� 6- 0 �, �. ( v <br /> EH 14.26 ,•• - _. <br />