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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �,(. ENVIRONMENTAL HEALTH DIVISION <br /> VY 160I E. IIAZELTON AVE. , PHONE (209)4fi8--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> j EXP RRS 1 YEAR FRY DATE 19§91ER <br /> (Complete in Triplicate) <br /> Thi <br /> Application is hereby made.toSan Joaquiinn Countty fora permit <br /> ty rdinancenatruct 5t9aandol862aend the Rules andeRegulationsdof Sans <br /> application is made 3n compliance <br /> Joaquin County Public Health Services. 1 <br /> 17 -� <br /> �� T h tx t,v CityLrL,_ Lot Size creag <br /> Job Address 2r� <br /> �;- Address <br /> Phone "'g <br /> Owner's Name <br /> S ���� Phone <br /> ... <br /> ConlraCId; �r + Address J License No' <br /> c - <br /> TYPE OF WELL/PUMP:: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well. ❑ <br /> W' OTHER ❑ Monitoring Well ❑ <br /> �! ,PUMP INSTALLATION f��' SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK tom--- SEWER LINES •^ DISPOSAL FLD. PROP. LINE <br /> 1� FOUNDATION Wg� AGRICULTURE WELL- OTHER WELL PITS/SUMPS <br /> INTENDED USE i _TYPE 01 'WECC PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C�] Industrial Open Bosom' -T• ❑ Manteca Dia. of Well Excavatio <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> V Domestic/Private ❑ Gravel Pack ❑ Tracy Yp g ��- Qcw <br /> I'! Public I-1 Other _' fl Delta Depth of Grout Seal Type of Grout <br />'r. I I Irrigation fA <br /> .��..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑I Type of Pump — H.P. - State Work Done <br /> Well Destruction ❑1 Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation w' Residence_ Commercial_ Other <br /> Number of living units: bedrooms <br /> Character of soil to a depth of 3 feet: Water table eptft�~ <br /> SEPTIC TANK I� ❑ Type/Mfg Capacity ompanrnents <br /> PKG. TREATMENT PLT. C7 Method of Disposal <br /> Distance to nearest: Well Founda ' Property Line <br /> .s d <br /> LEACHING LINE r C1 No. B Length of lines ,f Total lengthA :a <br /> FILTER BED .j ❑ Distance to neares• el{� -Foundation Property Line <br /> { <br /> SEEPAGE PITS i epiFi--- µ' Siie Number <br /> SUMPS LI Distance to nearest: _ _Weil.. Foundation Property Line <br /> DISPOSAL PONDS I� (H- <br /> 1 <br /> 1 hereby certify ,that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> 1. Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: ;,'t certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensa-tion laws of California." <br /> The applicant us all for aN requir d inspections. Complete drawing on reverse side. <br /> ii !� Z <br /> Signed �i' Title: Owe e2�` Date: <br /> y Ip° R DEPARTMENT USE ONLY <br /> + Application Accepted !Iby <br /> Date ^��^� Area , - - <br /> Pit,or ro t Inspection by ! Date Final Inspection by- <br /> 690 <br /> y _ Date-amu--� <br /> I <br /> Additional Comments::: <br /> Applicant- Return all copies to: San Joaquin County Public Health <br /> A Services, Environmental Health Permit/Services <br /> Gi .1601_E. .Haaelton_Ave.,.-P 0 Box 2009, Stockton, CA 95201 <br /> CK V <br /> FEE �' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO.• <br /> INFO <br /> tM <br /> -'H j � acs . 0� P f W <br /> rEH13241FEV.t/n51 � 1 I ~�i� `��� <br /> ? EFi;4-ZB l T' 0��� -- <br />