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APPLICATION FOR PERMIT ) <br /> SAN JOAQVIN COUNTY PUBLIC HEALTH SERVICES <br /> ? ce <br /> .� ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE CA CAPHONE 095201 3�2 + APR <br /> P O BOX 2009, 5 J��, ED <br /> 01'1 �� f`q�y <br /> XP RES 1 YEAR FROM DA E ED •ffRr=9 jy � <br /> (Complete in Triplicate) �~-�� fyf I <br /> permitr a to construct and/or install the work herein d03iJtio i*� San <br /> Application is hereby made.to San withuSan Joa4ulnin county' oCounty ordinance No. 549 and 1862 and the Rules and Regula <br /> application is made in comp I <br /> Joaquin County Public Health Services.r5 � Lot Size/Acreage 1V <br /> City <br /> Job Address L ii �Q �f (��Q j / q7 � C00 X35 <br /> S (1P�F1 V t 1 Co.—_ Address S[ ", Roy T+�T O ��Phone` <br /> Owner's Nameo A 6eurl�r� s�s(p Phone( 74 3'q7J <br /> PC �?�4i>» Address 1700 dcri�>� S�rj gS6z� License fVa. <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 1Z <br /> NEW WELL ❑ OTHER Monitoring Well <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR <br /> PUMP INSTALLATION © DISPOSAL-FLD.� -- <br /> �� SEWER-LINES- ?ITS/SUMPS <br /> DIST•ANGE TO NEAREST:_SEPTIC TANK-.�- AGRICULTURE WELL OTHER WELL <br /> FOUNDATION --. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing �L " <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0,i �ty� <br /> n Industrial (% Specifications <br /> n Tracy Type of Casing N.�4----7�� <br /> f:] <br /> Domestic/Private ❑ Gravel Pack Depth of Grout Sea!C_f1: S_-tTt Type of Gro <br /> I:1 Ocher n Delta <br /> I"1 Public Surface Seal Installed byO� <br /> 01 <br /> 14 Irrigation q Approx. Depth Eastern State Work Done .� �tK <br /> of Pump -- -- <br /> WP. �r(ov�' . 1;W <br /> F Repair Work Done (J Type Sealing Material 8 Aepth <br /> Well Destruction ❑ Well Diameter ��-- k, ��� Stihl <br /> Filler Material & Depth CTCG <br /> Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDI110N I I DESTRUCTION I I iNo septic system permitted if public sewer Is <br /> r � <br /> G installation will serve: Residence Commercial— Other <br /> ( Number of living units: Number of bedrooms Water table depth <br /> I Character of soil to a depth of 3 feet: Capacity--- No. Compartments <br /> SEPTIC TANK. i❑ Type/Mfg Method of Disposal <br /> PXG. TREATMENT PLT, I~7 Foundation Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE Cl No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line ��-- <br /> Size __ Number T - <br /> SEEPAGE PITS 11 Depth Foundation. — Property Line - <br /> SUMPS �_. D Distance to nearest. .Well — _ �- <br /> F- DISPOSAL PONDS 4=I <br /> iI hereby certify that I have prepared this application and that the work will be done in accordance with San.loaquin county ordinances, state taws, and <br /> i rules and regulations of the San Joaquin County following: that in work for <br /> l not <br /> Home owner or Iicenssuch manner astorbecome subjects to workman s coympensation lawsoof California,"he Contractor'swhich <br /> lhiri g or sub-contracting signlatura <br /> employ any person In <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." <br /> The applicant must call f I re iredbinspections. Complete drawing on reverse side, <br /> The <br /> {� <br /> Date: <br /> Signed X Title: <br /> R 0 TMENT USE ONLYI en <br /> + Date <br /> Ia <br /> kr Application Accepted by Data S <br /> Date_ — Final inspection <br /> Pit or Grout Inspection by <br /> Additional Comments: r <br /> I Applicant - Return all copies to: San Joaquin <br /> Environmental tatPSrv , County <br /> glthermit/Services <br /> 1601 E. Razelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> N 0 AMOUNT DUE AMOUNT REMITTED CASH � <br /> r EH 13.24 IREV.1/115) <br /> EA 14.26 556 . <br />