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Ii <br /> J-4 <br /> APPLICATION FOR ';PERM <br /> SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH S�RVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> + 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 - <br /> I XP RES 1 <br /> MAR FROM� <br /> I E <br /> (Complete in Triplicate) <br /> APPlication is hereby made to San Joaquin County for a permit to coned et and/or install the v01'KI � �. <br /> application is made in compliance vith San Joaquin County Ordinance No.' 549 and 1$62 and the Ruleap J �( 1 This <br /> Joaquin county Public Health Services. n of San <br /> ' Job Address <br /> City ° Lot Size/Acreage 10 <br /> Owner's Name Pat and 0-3.1 itche }i <br /> _-Address <br /> I Phone <br /> Contractor Osterberg & StewartAddress.2523 River Rd. Modest <br /> TYPE OF WELL/ UMP: license No. 946_ 670 Phone 209 537-57617 <br /> NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Q Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK q OTHER D Monitoring Well <br /> _ SEWER LINES1j DISPOSAL FLD.�_ PROP. LINEy�� <br /> i FOUNDATION AGRICULTURE WELL/ / OTHER WELL AM pITSJSUMPS/U3w£ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f7 Industria! .O Open Bottom ❑ Manteca <br /> y Oia. of Welf Excavation Dia, of Well Casing <br /> Domestic Priva[e �3[ Gravel pack L7 Traci <br /> 1'1 Public Type of Casing Specifications C1 Other fl Delta Depth of Grout Seal <br /> I I Irrigation r�Approx. Depth I I Eastern 3 Type of Grout t' <br /> Repair Work Done U T Surface Seal Installed by 6 <br /> Type of Pump ` <br /> Well Destruction 0 Well Diameter Sealing Material 6 Depth Stas Work Done <br /> Depth Filler Material i DePtt <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION [ I DE5TRUCTION 111 (No septic system permitted if public sewer is y <br /> V <br /> Installation will serve; Residence_ 1 available within 200 feet.) <br /> Gommercia! Other , } <br /> Number of living units: Number of bedrooms _ i <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. 0 Type/Mfg �j Water table depth <br /> PKG. TREATMENT PLT, ❑ Capacity <br /> No. Compartments <br /> Distance to nearest: Well I} Method of Disposal <br /> Foundation�_ Ai property Line <br /> LEACHING LINE Cl No, g Length of lines <br /> FILTER BED 0 Distance to nearest: yVe11 I� Total IengthJsize S� <br /> Foundation " l Property Line <br /> SEEPAGE PITS <br /> 1 1 , Depth Sise <br /> SUMPS 1.1 Distance to nearest: yye11 _ Number <br /> i{ DISPOSAL PONDS Foundation Ii <br /> ' ❑ �---�spraPe►ty Li no <br /> 1 hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la <br /> rules and regulations Of the San Joaquin County <br /> Hams owner or licensed agent's signature certifies the following: laws, and <br /> the <br /> { employ any person in such manner as to become subject to Workman's compensation' lawsoof Califormance rnians Contractor's <br /> work for Fhiring othis psublcant ecteinglsihnaltnot <br /> ure <br /> certifies the following: "I certify that in the performance o}the work for which this permit is issued, I!hall to <br /> tion laws of California." employ persons subject to workman's componsa- <br /> The applicant m for a I re ► d f ions. Complete drawing on eversq side, i <br /> Signed � �? <br /> Title: <br /> Date:il <br /> D <br /> ' FORD RTM T SE ONLY, <br /> Application Accepted by if GG C <br /> Pit or Grout Inspection by C' <br /> Date Area <br /> Date ~Z� Final Inspection by 3} � <br /> Additional Comments: iii Date I <br /> It <br /> Applicant`- Return all copies to:,' San Joaquin County Public Health <br /> Services, Ravironmental Health Permit/Sel ices <br /> .! 1601 E. Hazelton Ave.; P 0 Box 2009, Stockton, C.A 95201 <br /> FEE AMOUNT DUE <br /> AMOUNT REMITTED CK " ii , <br /> INFO CASH RECEIVED By <br /> DATE PEtiMFT'NO. <br /> • <br /> Ell T3.71 lRf%•ries! <br /> ��,.�� <br />