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�! APPLICATION;"FOR PTRI![IT <br /> SAN' i:YOAQi]IN COUN������7BLIC _HEALTH SRRVICHS <br /> E1'f1 htONidENTAfi HEARTH D I'V I S I014 <br /> 1601 ICs HAZELTON ,AVE: ; . PHONE (209)461'3-3420 <br /> P O SOX 2009i SSTOCKT ON CA.:95201 <br /> Pli"IT EXPIRE$ L Y13AR FROM DATE jBSUSD <br /> (Complete in Triplicate) <br /> Applicitibn is hii4b$ made to San jc,64diin Coiuity >or a permit to e6hetriict and/or,iiiiiAi the i+ork hdreiii desci ibed: This <br /> !!! application is srad2 in Ce 'liance frith Odun j6dqui I Coiihtyr Ordiniiuice 190: 549 aril 1862 and the Rulee and Aegulationa of Ban <br /> Joaquin County Public Health Servicdi. <br /> Jab Address C- i -f cityC3'# 1,„�Yfr, Lot Size/Acreage <br /> Owner's Namfi Address' s. , :W SUN Phond 477-0401 <br /> Contractor Address bc6n5e No. 1Phone 04&A81 I <br /> TYPE OF WELL/PUMP:., NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMO INSTALLATION =SYSTEiuI I f AIR ❑ OTHER O Nlonitoririg Nau" ❑ <br /> DISTANCE TO NEAAC0.1 SEPTIC TANK SEiT A UNEs __^__�" NSPOSAL fLD; _ PROP. LINE <br /> .x.,„ FOUNDATION AGRTI,l <br /> ICULRE WELL " OTFfEFi 1iVELL FITS/SUI41P$ <br /> INTENDED,IiSE TYPE OF WELL PROSUM AREA CONSTRUCTION SPEC1FiCATIONS, <br /> n Industriai ❑ Open Bohoin 'Cl Manteca Dia of Wbll EkciVAliOn Dia. of Wall Casing <br /> Domestic/Privaie L1 GraJ61 Pack ❑ Ttacy Type of caging Specificatiorii <br /> Publlc 1-1 Oiher C1 Delta Depth of Gout SeAi Type of Giorit <br /> I I IrriuMioiii —Aor46x. Ddpih 11 Esil6iii Surface Sial lnstalldd by" <br /> Repair Work DontF" L7 Type 6f PumpaL�H.F. 5tatrf 1lVoili Doric J '" r (��, <br /> Well Destruction , ❑ Well Diarinbtei Sealing atbrial.� D4tfi .. <br /> 1 <br /> Npth Finer 11at2ri8i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> AvAiiabia Within 200 16e0 <br /> Installation will "646: fie ldeincd_6 t4or6&tdibl Other <br /> Number of living units: Numbbr 61 bsdroo'ml <br /> Choractet of soli to a d6pth 613 feat :f VWdtdr table dbptfi <br /> SEPTIC TANK. O typb/Mtg Capacity. No. Conipartnienti <br /> PKG. TREATMENt PLt;0 Method of Disposal <br /> Distance to hodeiia- Well Eouhditiori Property Line ^ <br /> LEACHING LINE : b " No. 6 Length of lintii t-fotAf lerigih/"situ <br /> FILTERSED [3 ;Diitan69 io iiei►9§ti Well s f`oiiiitlaiibn_ M lirbpertY Line <br /> x - <br /> SEEPAGE PITC 1 1 Dej tfi Sifb NuiYabei <br /> SUMPS LI bistAnce to nti f"I: WAff • PoliFld9tioT propaityi Lind h <br /> DISPOSAL PONDS—.. U _ } <br /> I hereby certify that 1 have prepared ihlb appllcail6h and that thb work will bb done In eccolrdance With Sen Joaquin county brdinances; State lawn, and <br /> rules and regulitione of the San Joaquin dounty t <br /> Home owner or iicehiAd atg6hi'e itigh4ture certifids the following: °'i bbrtify that 1n the prirfoiniance of thb W6ik for"Ich this-&Kilt 13 issued, I shall not <br /> employ any pardon iii ouch inanndr a's ib bbconis d'ubjeci to workrr'ian'$compensAiiori laws of califohiia."Cohtractor's hiring&Bub-coniracting signature <br /> Certifies the follo%mrio: "I Certify 1hbi in the perfoth ahcd of the Work for`which tin's 06ifnit is fisuad; 1 `shall Wiiploy person's subject to Workmin's compansa-" <br /> tion Iowa of Celifornl5.,' <br /> The applicant must coil for.ii l req ired 1 ,1SeC r drawing oir tri"iiI4 ild6. <br /> Signed t Tu18. ,: AETAIL SAUS Dine: <br /> O" 0EPA1111IT- ENt Gilt ONLY <br /> Appllcetlon Accdptdd by t +. �3N1�s �[ Date '� " �' <br /> 4 Aria <br /> Pit or Grout Inspection byDate Fihel lrispection by ✓ bate <br /> Additional Comments: <br /> Applicant = Rrturn in topieo to: Bari Joaq,tiin County Pubiic 96iltlth <br /> 3ervicehi Envirohmentnl Health permit/$erviee8- <br /> 1601 E. Hazelton Ave: -P 6 Box 20091 Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT fiEmirrED CK Vt D liY GTE PERMIT N <br /> INFO CASH ,.. RECEIEI - AO.] /) <br /> • EH <br /> EH TT3-4-26 <br /> 2J(REV.t i a s) &�i ��}it � � • j <br /> ' <br />