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APPLICATION FOR PERMIT <br /> gpN�JOAgU I N COUNTY PURL I C HEALTH a�tV I CES <br /> ENVIRONYSNItAL HEALTH DIVISION <br /> 1601 E. HAZSLTON AVE, PHONE (209)468-3420 foP"vk <br /> P O BOIL 2009, STOCKTON, CA 95201 <br /> ......,�..r p�IRE 1 yROId DATE ISSU <br /> (Complete in Triplicate) <br /> Application is her 11Ylde LO San Joaquin Countyina Pe rmiO titnencenNoru549 ando1862sand the Rules ande <br /> eRegulations of SanThie <br /> application is made in e-viiance vith San Joaq <br /> Joaquin County Public Health Services. <br /> 7b iff'T - Lot Site/Acreage <br /> 111 I IV,�o t �Ar•liF Tcity --- <br /> Job Address � C ✓JAe-/t o -o S /- 3 <br /> TRXT <br /> � <br /> O r'.11 9 �G D Phone 1'/S 89/-36�� .,,. ✓ H/G Address 9 Li L q N _ <br /> owner*@ Name 3 a r 3 0 itt�G C i.4- su l r/E f3 <br /> r �.QNG/�a ,SY9�.z8 Phone <br /> B CROOt,• G License No.__ <br /> Contractor �' �- Address <br /> WELL REPLACEMENT O DESTRUCTION Out of Service Well ❑ <br /> NEW WELL C OTHER O Monitoring Well Ci <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION O DISPOSAL FLD. PROP. LINE <br /> SEWER LINES — ------- PITS/SUMPS _..� <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ERE9�7� <br /> TIONS Dia. of Well Casing <br /> --Industrial O Open Bottom O Manteca Specifications <br /> 171 Domestic/Private O Gravel Peek O Tracy Depth of Grout Seal Type of Grout <br /> 1'1 Public <br /> Il Other fl Delta <br /> x. Depth 1 I Eastern Surlseo Soul Insall <br /> ed by <br /> I I Irripstion _ApproH.P. State Work Done _ <br /> Repair Work Done U Type of Pump Sealing Material i Depth <br /> Well Destruction O Well Diameter <br /> �. tiller Material i Depth <br /> Depth NO <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION I 1 REPAIR/ADDITION I I DESTRUCTION I I availablerw thin 200 permitted it public sewer is <br /> Installation will serve: Residence _ Commercial_ Other ____---- <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soN to a depth of 3 feet: Cspscity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. O Foundation — Property Line <br /> Distance to nearest: Well <br /> Total length/size ' <br /> LEACHING LINE O No. b Length of lines Property line <br /> ❑ Distance to nearest: Well Foundation <br /> FILTER BED ' <br /> Sire Number i <br /> SEEPAGE PITS 11 Depth Property Line <br /> SUMPS LI Distance to nearest: Walt Foundation <br /> DISPOSAL PONDS O <br /> d that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 1 hereby cortifY that I have prepared this application an <br /> rules and regulations of the San Joaquin Count? <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 /> ture <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hirin ° r n's comng pensa- <br /> tion <br /> the following: "I certify that in the performance of the work for which this permit is issued.I shall empl or u pe <br /> tion laws of California." 1 <br /> The applicant �C 11 for all requ JnspectioM. Complete drawing on reverse side. Q Z A? <br /> _Y �! Title �Ois ?ES Date: CJ <br /> - FOR DEPARTMENT USE ONLY <br /> Data Area46— <br /> Application Accepted by � ZZ <br /> - 4z4. <br /> Pit or Grout Inspection by <br /> 41Dat ,Tt Final Inspection by Daf�J <br /> Additional Commente: t <br /> Applicant - Return all copie° tot Sea Joaquin C tY Public Health <br /> Services, Eavirotuaental Health Permit/Services 95201 �vVV <br /> 1601 E. Ratelton Ave.. P 0 Box 2009. Stockton, �) 1 <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED HY DATE PERMIT NO. / r <br /> INFO ((� ,(;-/' I <br /> EH 1724IREV.I/mSt it �(�,V� 'l. c- /'1�' 4 <br /> E H 1 2e V 'j <br />