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FV <br /> . , APPLICATION`i N C077Y-PUBLIC HEALTH SERVICES �! j <br /> ERVIRONh*oIli1TAL HEALTH DIVISION <br /> SAN JOAQUIN COUNTY PUBLIC HE C S <br /> r rr ENVIRONMENTAL HEALTH DVM, , PERMIT <br /> "# 1601 E. HAZELTON 4,Yp. , .PHONE (209)458-3420 <br /> P O BOA 2009," TOCKTON, CA 98201 s; <br /> PFB <br /> XIT EXPIRES 11YEAR FROM DATE UED <br /> (Complete ;:in Triplicate) <br /> Application is hereby made,to San Joaquin County for a::permit to construct and/or install the work herein described. 'Phis; ' 1! <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862'and"the Rules and Regulations of..San <br /> Joaquin County Pulb�lic Health Services. " l <br /> Job Address / 2n CA r", O� City :5tS:Mnag <br /> Lot Size/Acre a <br /> Owner's Name �� r 0, :LC_P timet]. Address I Phone <br /> Contractor(4Ue.f i_J ►-,A�`T— Address a�i3 F,�'z�r 4—%A ii;�. - License <br /> _ 7 <br /> TYPE OF WELLIPUMP: NEW WELL O WELL REPLACEMENT 0 DESTRUCTION D Out of Service Well Cl <br /> .,, PUMP,_INSTALLATION ❑ SYSTEM-REPAIR �!"�BOTHER.;❑ ,k.,rM°nfcoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.: ' PROP. LINE <br /> FOUNDATION AGRICULTURE�WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA{. CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom © Manteca 7 Dia:"of Well Excavation .bia. of Well Casing I 'i <br /> {l Domestic/Private ❑ Gravel Pack C1 Tracy ': Type of Casing SC La cL IQ 7 d Specifications <br /> i'I Public la Other fl Delta Depth of Grout Seal y `" 'Type of Grout <br /> r ii ,.8,.-mc <br /> I (Irrigation _7�Q Approx. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> ~ Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: " NEW INSTALLATION I 1 REPAIR/ADOIT4ON I I DESTRUCTION l I (No septic-system permitted if public sewer is <br /> a. within 200 feet.) <br /> Installation will serve: Residence_- 'Gommarcial Other E SANJOAQLTIN Ct `PUBLIC HEALTH SERVICES <br /> Number of living units: Number of bedrooms -__ � ENVIRONMENTAL RMTH DIVISION <br /> -Character of soil to a depth of 3 feet: �. t taP <br /> SEPTIC TANK- O T e/Mf — f' ^ tIM <br /> ' r`' ' <br /> YP 9 pacts No. Compartments" { <br /> PKG. TREATMENT PLT.❑ + � � $$ ff QQQ�fr 'Method of Disposal f <br /> Distance to nearest: a FountiStidrY"L Property Line <br /> LEACHING LINE CI No. & Length of lines PERMIT/`c t?: �r�rTotal length/size" <br /> FILTER BED 0 'Distance to nearest: Well Foundation" Property-Line <br />_ _, SEEPAGE PITS 1 I„vDepth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Pro ,.r <br /> party Line <br /> DISPOSAL PONDS C1 _ . .,.. .. . <br /> I hereby certify that I have prepared this application and that the work wil;:be done in accordance with San Joaquin.county ordinances,,state laws,:and <br /> rules and regulations of the San Joaquin County i ;I 111 <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 /> employ any person in such manner as to become subject to workman's compensation laws of California."Con'actoi s hiring or sub-contracting signature;, <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compsnsa=� <br /> tion laws of California." <br /> The applicant ust call for all required inspection . Complete drawing on reverse side. <br /> Signed Title: �UiY_O_SL �1 Date: /'� <br /> FOR DEPARTMENT USE'ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Data Finallnspection by Date <br /> w <br /> Additional Comments: <br /> .me s i <br /> Applicant - Return all. copies to: San Joaquin County Public:Health = <br /> Services, Environmental-HealthrPermit/Services <br /> 1601 E. Hazelton Ave.:, P 0, Box 2009, Stockton, CA 95201 i rj <br /> FEE i AMOUNT DUEAMOUNT REMITTED CK i 9 RECEIVED BY DAT[ r; 1 # 'PERMIT'NO. <br /> 'INFO' CASH , <br /> •?_.EH 14.20- _ _- ..».E <br />