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v �73 <br /> / APPLfgATION FOR PERMIT <br /> 00SANT .IOAQUIIY CUVnTY. RVBLIC HEALTH SERVICTs,S SVr*'�NE� <br /> ENVI40NMENTAL "ALTH DIVISION ; <br /> 1601 E. HAZELTONI AVE. , PHONE (209)468-3420 <br /> P 0 BOX'.2009, STOCKTON, CA 9520].,•,'1:4 ..F.,_ <br /> SIT i)R. YEAR ���- � o ,IU <br /> F D SSUSQ I ,F c- ., ,� r <br /> (Complete in Triplicate) <br /> ,'Y4$s�>1:.. <br /> Application is hereby made•to San Joaquin County for a permit to construct and/or' instal3rthe' rokk Oa eli �dese ib c* This <br /> application is made in coupllance with Ban Joaquin County Ordinance No. 5!+9 and 1862 ggd..yhaHules>aad jLegulakiona..Of San <br /> Joaquin County Public Health Services. <br /> - - ; �Z i{i #jl �Jets3la.r- <br /> Job Address `f ; _ -- _ CitK, t Sias/Acrange F Ft ';:t it0f!- ? <br /> 0wnar's N a m a �� J�t7_+1-4 Address Phone 1 <br /> 7 <br /> Contlactor ' /�" A f Address RQ q 7 Licensetoo: Phone <br /> TYPE OF WELL/P MP: EW WELL ❑ WELL REPLACEMENT WrDESTRICTIQq M of;8eir1►> 0`Vg11 ❑ <br /> 7 PUMP INSTALLATION W-" SYSTEM REPAIfi ❑ 1 OTHER El � i 40.11$"Nell <br /> �L� � SEWER LAVES �d[ZDISPOSAL FI.D� ,p <br /> DISTANCE TO NEAREST: SEPTIC TANK ' / ' <br /> .. __ �_•PROP�LlNE <br /> 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS!$UMR , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r . <br /> C i IndustrialQ:O en Bottom ❑ Manteca Dia. of Weil Excavation T pts. 01 4i11a11 Liar jn9$a <br /> el omestic/Private CTZi"'Ial Pack ❑ Tracy Type of Casingq €SpaCrftGatian>ic; _' _ <br /> I I Public I:} Other fl Datta Depth of Grout Seal 'fpp of Gfou} ' <br /> I I IrriUdlian __.Approx. Dept I Eastern - Surfaca Saul Installad by -�- <br /> Repair Work Done U Type of Pump H.P. _ State VYark.Darie { 1¢ t <br /> Well Destruction W),- Welt Diameter 42 Sealing Netenial & Depth <br /> r Depth - - Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I IN0 "P or.a Idem permitted"if pliblic'`ewer is c <br /> available othttr 200 feet.) } <br /> Installation will serve: Residence T_ Commercial Other i T, ql <br /> r 1 <br /> Number of living units: Number of bedrooms + <br /> Character of soil to a depth of 3 feet: Wates table depth <br /> SEPTIC TANK ❑ Type/Mfg - Ca acitY 1 No. CPOentaal• <br /> PKG. TREATMENT PLT. ❑ Meth as <br /> _ <br /> � <br /> ♦ `"' <br /> ...'arstance to nearest: Well Foundation Property Llnr ,� } <br /> LEACHING LINE CI No. & Length of lines Total Iengthfise y a f <br /> FILTEM BED [_! Distance to nearest: Well.— Foundation Properly Lin6 <br /> t . <br /> SEEPAGE PITS I I Depth Size 1 <br /> Number . a <br /> SUMPS <br /> l_l Distance to nearest: Well � Foundation Props <br /> DISPOSAL PONDS ❑ <br /> I hereby certify the; f have prepared this application and that the work will be done in accordance with $_ } Y !r1 #. �4ate layers and :✓ ' <br /> eft ggin count ortiln <br /> rules and regulations of the San Joaquin County s 1 E <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the pertormanca of the work lot which this Perft}jt .1f31rgdj:,f_eEtitNl.pot <br /> employ any pe manner as to become subject to workmen's compensation laws of California." Contractor's fairing or sub:cgntraa:ting signature <br /> certifies aha owing: "I c rtNAinrdo;WQC,�of the work for which[his permit is issued, I shall employ�eroone rrarbjact to lfygjkrrMntion laws California."The appl' ant m 1 f allC plate drawing oSigned ` t1 Title: LrL aai i <br /> • F Data: <br /> PARTMENT USE ONLY ` F ° 1 <br /> - . . <br /> Application Accepted by Data Arse <br /> 4 <br /> k <br /> Pit or Grout Inspection by Dale �� , � Final Inspection by loots. ^_ t <br /> Additional Comments: /� <br /> Aiz <br /> Applicant — Return all copies to: San Joaquin County Public Heal h . <br /> { <br /> Services, Environmental HealthTermit/Services^ <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 � } <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED SY DAR � PEAMI7 it+IA <br /> . EH 13-21 iREV ,.net <br />', EH 11.26 1" _ - i <br />