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r APPLICATION, FOR PERMIT �) <br /> ;:�+ <br /> SAN JOAQUIN'€ COUNTY'PUBLIC HEALTH SSRVICTS ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E:­HAZFLTON AVE. , " P$ONE (209)46$-3420 " <br /> P -0. BOR 2009; $1'OCHTON; 'CA 95201 <br /> >a t IT EXPIRES 1 .YTs ft R x.ISSUM <br /> (Complete in .Triplicate). <br /> Application is hereby made.to Ban Joaquin-"Countylfor�a permit to construct acid/or install the cork herein described: This <br /> application is made in compliance with Safi Joaquin Chanty Ordinarice'No. 549 and 1$62 and the Rules.atrd Regulations of San. <br /> Joaquin County. Public Health 8ervicea.< t r ! 3w4 -'.: <br /> e!o M�vEK -r�jc t`�TC�N t�3 A City ST .K*n� 'Lot Siie/Acreage <br /> Job Addres . <br /> . ,r / I /? zo0 <br /> 1'v'v r� L+JC. vE1 /VZV16Cf W-4GV(JT GEr APhone !S - 353 <br /> Owner's Name <br /> Address a . <br /> [ }' kT'eibo <br /> Contractor Addrbss� n �f Llt:ense No.cS �g"Phone ��� <br /> TYPE OF WELLIPUMP: NEW WELL,0 WELL REPLACEMENT ❑ _ ' i. DESTRUCTION Liout-of Service Well 0 <br /> "'` -Monitoring Well £ ' <br /> ,s, OTHER �! <br /> O " �� SYSTEM REPAIR.L] <br /> PUMP INSTALLATION ; F� � i.. " <br /> DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES"';x,_!50 DISPOSAL FLD, PROP. LINE <br /> FOUNDATION' AGRICULTURE'WELL T OTHER WELL PITSISLIMPS !r <br /> INTENDED USE TYPE OF WELL t PROBLEM AREA r CONSTRUCTION SPECIFICATIONS <br /> f: <br /> [] Industrial C] Open Bottom_ 0 Manteca �" Dia: of Well Excavation _fes! Dia. of Well Casino y° <br /> t <br /> i C"a Domestic/Private ravel Pack j'.❑ Tracy 4: :7ype of Casing Specifications <br /> I'1 Public I 1 Other ' C1 Delta,. Depth of Grout Seal �� Type of Grau <br /> I 1 Irrigation �Zr_Approx. Depth i I I Ess4rn 1.Surface Seal nsialled by <br /> Repair Work Done 0 Type of Pump �' H P: Siste'Work Done <br /> k <br /> Well Destruction ❑ Well Diameter , Sealing Material i Depth�Atr6,+u1TT_ 7d _ - <br /> Depth , 0'2 ik. Filler Materiel R:Depth /N� C;rJT ttoC? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR'/ADDITION I 1 I DESTRUCTION I I ANo septic system permitted if public sewei is iF <br /> ",available within 200 feet.) <br /> Installation will serve: Residence— Commercial°.° Other <br /> ,Number of living unite: Number of bedrooms � d ;:.•, "r. fi <br /> Character of soil to is depth of 3 feet: _ =---='Water table depth <br /> SEPTIC TANK 0 ' Type/Mfg "- Capacity' + No. Comportritenti [ <br /> PKG. TREATMENT PLT.0 f"� 'i i Method of Disposai Jr.. <br /> Distance to nearest: Will foundation Pioperty Line fi <br /> LEACHING LINE. C1No. & Length of lines i- Total length/size r <br /> FILTER BED C7 Distance to nearest: Well Foundation Property Line : <br /> SEEPAGE PITS I I Depth--- S40 ___ Number <br /> SUMPS Ll ' Distance to nearest:• . Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <br /> I hereby certify that 1 have prepared this application.and that the work will be done Irl accordance with San Joaquin county ordinances; state laws, and ` <br /> ruies and regulations of the San Joaquin County< i # `-; <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, t shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or out-contracting signature t <br /> certifies the following: "I Certify that in the performance of.the work fo'r which this permit is issued; I shad eiiipioy persona subject to workman's compensa <br /> tion laws o alifornia."= s } { <br /> The app Cu all for all requir in pectioni:"Complete driwing on reverse side. :'e t <br /> '' tAus (C��sr� iU6p <br /> Signed _ };•Title: (�^ Date: , <br /> { 44 <br /> e FOWDEPARTMENT USE ONLY : r' <br /> Application Accepted by r Date- Aida <br /> V <br /> t <br /> Pit or Grout inspection,by } [ Date F,inel Inspection by- '- Date ( <br /> Additional Comments: <br /> Applicant - Return e11 copies to: San Joaquin County Public Health . + " j <br /> Services, Envirohmental Health?Permit/$ervieee . € <br /> 1601 B. Aaselton`Ave.; P 0 Box52009, Stockton, CA 95201 <br /> INFO TEE <br /> AMOUNT DUE AMOUNT REMITTED �",ASH RECEIVED By DATE PERMIT"NO. <br /> f. ,EH 13L24 IR EV.11 51 Q �- i •.-, 1. ,. _" LL_ /] e <br />} EH 4-2e <br />