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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 46$-3447 I <br /> TR ISSUE& <br /> (Complete in Triplicate) <br /> t to Application is hereby made to San JoahanuignCounty fora permi Ordinancenfioru549&ando1662 and thee%aes andeRegulationsdof Sans <br /> application to made,in eomtplisnce"vi <br /> Joaquin County Public Health Services. Lot site/Acreage <br /> � City <br /> Job Address M4 6"U 7 <br /> [[�sff � Phone <br /> IG/ Address <br /> Owner's Name � <br /> /��JJ , � License No. Phone <br /> Contractor�,� ��C � - '��5 Address <br /> WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ <br /> EW WELL OTHER ❑ Monitoring Well <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR 0 <br /> PUMP INSTALLATION; PROP. UNE,?,7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �O jAj® -5; T, PIT5ISUMPS "� <br /># FOUNDATION � AGRICULTURE WELL `rOT E WE LLsC--- <br /> 1TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia of Weil Casing 4 <br /> INTENDED USEpia, of Well Excavation — <br /> C� 0 Open Bottom © Manteca Specifications. <br /> Industrial <br /> 1 n Trac. Type-of-Casing- ! <br /> ^ Domestic/P_rivate WGfovei_P_ack..,,s.:...�;r Yom' Type of Grout <br /> i'1 Other © Delta Depth of Grout Seal <br /> Ci Public Sint to-Saul Installed by <br /> GI Irrigation ;Z �.lAPprox}Depth 0 Eastern , / 2= State Work Done <br /> = H.P. <br /> Repair Work Done U Type of Pump � SeZ-rng-lkaterial i Depth <br /> Well Destruction © Well Diameter — �gltiri7t1�1r�ePth - F <br /> F TYPE OF SEPTIC WORK: NEW"INSTALL-ATION n REPArR1ADDITIONyCf DESTRUCTION G avfailabPo erwithin 200 feeti1fed rl ptrbr�c mower is �J <br /> Installation will serve: Residence Commercial-�-= O.titer.,,._a— <br /> Number of living unite: Number of bedroomsi J `af '- Water table depth r- <br /> p Character o1 soil to a depth of 3 feat: No. Compartments <br /> k SEPTIC TANK. ❑ Type/Mfg ` y Method of Diagonal y; <br /> PKG. TREATMENT PLT. Cire g r Property Line -?F <br /> ell Foundation <br /> - <br /> Distance to nearese: T <br /> r , '., . r e. Tat l length/size 1 ! <br /> " LEACHING LINE 0 No. & Cength of lines -_ s `Foundation ( `" Property Line <br /> I �t <br /> FILTER BED t� Distance to nearest: <br /> N/eA <br /> Number <br /> SEEPAGE PITS I I 'Depth j i Sire <br /> Foundation Property Line ----. <br /> SUMPS Ll Distance to nearest: Weil — , <br /> DISPOSAL PONDS 0 <br /> k I hereby certify that I have pfepared this application an "that the work will be done in'accordance with San Joaquin county ordinances, state laws, and a. <br /> (vies and iegulation"f-ths.San Joaquin County <br /> f i <br /> i <br /> Home owner or licensed agent's signature certifies the following:,',I cenify that in the perlormance of the work for which this permit is issued, l signature <br /> she not <br /> employ any person in such-manner as to become subject wofkman'•s.compenaation laws of ed, I shall emploContry <br /> ptosonsisubjeering rt to work man!scompensa• <br /> certifies the following: "t certify that in the periorrriancerof-the-wdrkaor' ich this Permit is issued, !chalk employ pe <br /> tion laws of California." ' <br /> Theapplic mu 'f r-p requir s. Complete drawing on reverse <br /> ilia: Date. G <br /> t Signed - _- <br /> i --FOR EPA_RTMF T USE ONLY <br /> �-� 1 �7 Arta 7i 1 <br /> Date <br /> I ' � <br /> Application Accepted by u <br /> Data <br /> pit <br /> 3 rO <br /> Final inspection by �•J <br /> Pit or Grbut Inspection by - j ti e -+D` .. jf ,,� .�'°•' t <br /> k Additional Comments: -- G J k f t.0 f y J O 5 <br /> Applicant - Return all coples4tot�gAX JOAQUIN COUNTY PUBLIC HEALTH gSRVICS3 <br /> - ENVIR445 NONMENTAL <br /> HEATH OIVIsION 200gERMITCKTON1CCA 95201 4 <br /> SAN S <br /> CK RECEIVED BY DATE PERMIY NO. <br /> ffFAAMOUINT DUE AMOUNT REMITTED CASH <br /> C{ vfH 1]•2�tREV.VMSIV� <br /> EM i1•Ie Apt. - <br /> r�. <br />