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.•. .� APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE CA09)468-3420 3�yD-03 <br /> .. P O BOIL 2009, STOC " .7vo <br /> EXp RES 1 YEAR FRObA DATE is ; <br /> (Complete in Triplicate) ���-23a - 2-41 <br /> � a <br /> Regulations of San <br /> n hereby eoSan JoaquiinCounty for a permit ato inance Noru549&ando1862s and the tall eRules a ndwork ein escribed. This <br /> licatio compliance with San S quip County 1 <br /> application is made in comp CaR +P4vi Z: 16 �' 040 �5eu�774 ¢ �',1Z+� 7`.575).. <br /> ,toaquin County Public Health Services. �� Lot Size/Acreage <br /> z -`o� o� o may ^`= <br /> Job Address Phone <br /> Owner's Name - 3 <br /> ljT icense No. Phone <br /> f'fN dress ' pESTflUCT10N <br /> I Contractor WELL REPLAGEMENT ❑ <br /> NEW WELL ❑ OTHER ft-b Of <br /> fir- nf S <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD.�.--- <br /> DISTANCE TO NEAREST: SEPTIC TANK ��� SEWER LINES ___ -- PITSISUMf�B <br /> FOUNDATION �-- <br /> AGRICULTURE WELL ...�.�— OTHER WELL��.-- <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE C1 Manteca Dia. of Well Excavation S <br /> n industrial U Open Bottom Type of Casing <br /> ' -af t3rryat <br /> (-] Domestic/Private ❑ Gravel Park ❑ Tracy n Delta Depth of Grout Seal , <br /> {'1 Public Cl Other <br /> _AQprox: Depth 4 I Eastern Surface Sedt installed by State Work Done <br /> I i Irrigation � H P <br /> Repair Work Done 0 Type of Pump Sealing Material k Depth <br /> Well Destruction ❑ Well Diameter - Filler Material b Depth <br /> available within 200 leei.i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION i I DESTRUCTION I 1 (No septic system permitted it public sews r <br /> Depth is <br /> Installation wilt serve: Residence i Commercial— Other — <br /> ( Number of living units: Number of bedrooms Water table depth <br /> r Character of soil to a depth of 3 feet: Capacity--- No. Compartments t n <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal v) <br /> I Al � i <br /> PKG. TREATMENT PLT.❑ Foundation' Property Line <br /> Distance to nearest: Well Foundation'— <br /> a Total length/size <br /> LEACHING LINE Cl No. & Length of lines Property Line <br /> FILTER BED • <br /> Cl Distance to nearest: Well Foundation �--- <br /> � i <br /> Sl 1 Depth a Sire <br /> SEEPAGE PITS <br /> Number <br /> , t Foundation Property Line <br /> fSUMPS s.,1 1 Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> r lication and that the work will be done in accordance with San Joaquin county ordinances, <br /> I hereby certify that I have prepared this appstate laws, and <br /> rules and regulations of the San Joaquin County that in the <br /> d, I shall not <br /> Home owner or licensed agent's sign to become subjecttow1ak man'srtcoympensation lawsoof California."oContractor's work for hir ng or sub-contracthis permit is ting signature <br /> employ any person in such me persons subject to workman's compensa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ pe <br /> ± tion laws of California." <br /> f The applicant must.call for all re uired inspections. Complete drawing on reverse side. <br /> Title: <br /> N6 r �L��JS7 _— Date: <br /> 16 <br /> Signed <br /> F p APARTMENT USE ONLY <br /> Date�t� Area <br /> Application Accepted by 1d� Date - <br /> f 1 Date��---- ulnspectio by <br /> I Pit or Grout inspection by / � 11 <br /> Additional Comments: r quia County Public Health � � V r <br /> Applicant - Return all copies to: San ,7oermit/Servicee <br /> CE1�� �rT <br /> Services, Environmental Health Fe <br /> i 1 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED By DATE PERMIT N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 13.24 tREV.I/R 5) } <br /> EH'14.26 <br />