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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p• HAZjkLTON AVE. I PHONE O BOR 2009, STOCKTON, CA 952013420 <br /> l <br /> EXP RES YEAR FROM DAT <br /> (Complete in Triplicate) <br /> work herin describe . Thi <br /> Application is hereby made to San Joaquin CountoCoy rit to dinancenNo 549struct8ando1862sand thee <br /> eRules andeRegulationsdof Sane <br /> application is made in compliance with San Joaquin <br /> II Joaquin County Public Health services. T- <br /> City Lot Size/Acreage <br /> li TJob Address /� J�� <br /> Address 3 I 2447 Z J - - Phone <br /> Owner's Name ,1 //��// Cj to <br /> License No.`k -Phone / [1 <br /> Contractor ddress <br /> WELL REPLACEMENT C� DESTRUCTION O Out of Service Well G3 <br /> TYPE OF WELL/PUMP: N W WELL OTHER p Monitoring Well L7 <br /> PUMP INSTALLATION SYSTEM REPAIR <br /> DISPOSAL FLD.--� PROP..i ! <br /> EWER LINES •_—. ,.� --- `�� PITS/SUMPS <br /> t- DISTANCE TO NEAREST: SEPTIC TANK .- <br /> FOUNDATION 2 AGRICULTURE WELL .�- OTHER WELL_^ —^ <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / /r � <br /> - INTENDED USE —_—---,_� - Oia:of Well Casing Cv <br /> ,"p-Open Bottom © Manteca Dia.'of VJell`Excavation-"'""r� <br /> Cl Industrial'"'": Type of Casing Specifications <br /> ' j Gravel Pack Cl Tracy <br /> DomesticlPrivate lad Type of Grvut <br /> (-I Ot er n Delta Depth of Grout Seal <br /> 11 Public 7 � <br /> I l Irrigation SWApprox. Depth l I Eastern �ace Seal Installed by <br /> H P State Work Done , <br /> Repair Work Done U Type of Pump sealing Material & Depth Yam <br /> Weil Diameter <br /> Well Destruction Fi'Iler Materiel& Depth' f <br /> Depth11 <br /> r TYPE OF SEPTIC-WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION l I a lvailableseptic <br /> within 200 faeft`ad it public sew <br /> er <br /> Installation will serve: Resid a Commercial Other �_�--- <br /> ' Number of bedrooms a `� <br /> Number of living units: �y - a' Water tabie depth rr <br /> Character of soil to a depth of 3 feet: } <br /> r�`-' Noy Compartments <br /> 0 Type/Mfg <br /> t SEPTIC TANK Capaci;yam - <br /> i <br /> �* j= t . yrMethod-of Disposal <br /> PKG. TREATMENT PLT.G7 <br /> Foundation Property Line' <br /> Distance to nearest: Well „ <br /> �Totshlength/sRei # <br /> Y LEACHING LINE Cl No. & Length of lines Property Linea f <br /> FILTER BED Ct Distance to nearest: Well Foundation s <br /> Number <br /> l •SEEPAGE PITS [ I Depth Sire + <br /> ! } ,1�. � Property Line <br /> SUMPS LI Distance to nearest: Well Foundation i <br /> • DISPOSAL PONDS D '.._ --•--t--#� w. <br /> 1 <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in,'a; ccordance with San Joaquin county ordinances, state laws, and <br /> I rules and regulations Of the San Joaquin County <br /> 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 /> i employ any-peraoh in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signet: <br /> l certifies the following: "1 certify that in the performance of the work for which this permit is iesued,'I shall employ persons subject to workman's compensa <br /> tion laws of California.- <br /> The <br /> alifornia.The applicant uire , Complete drawirig on revery de. <br /> Date: <br /> Signed title: t <br /> �a FOR DEPARTMENT USE O Y <br /> Date - Q fl Area <br /> Application Accepted b <br /> Pit or Grout Inspection by D,ate -•.-- <br /> _ f�_ <br /> y 1 2d Final Inspection by Date ' <br /> F Additional Comment <br /> Applicant - Return all copies tot San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave:, P 0 Box 2009, Stockton, CA 95201 <br /> "AMOUNT REMITTED CK °- RECEIVE(] BV y,.�DATE PERMIY N0. <br /> = INFO AMOUNT DUE"""° CASH <br /> t EH 13.24 IREV.I/n s, <br /> EH 14.26 <br />