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,Y APPLICATIONS 'FOR PERMIT
<br /> SAN JOAQUIN COUNTY°'PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH-:DIVISION
<br /> .1601 E. HAZELTON'AVE. , PH6NE' (209)468-3420 `
<br /> P O BOX 2009`,`gSTOCKTON( CA' 95201' ') ;:r- ;•, -!. `+
<br /> �'" REIT. ."10€�ncre, ti: ��!-€YI.Y) •�f y.�Z t �,_t :i. t,, ,.
<br /> EXPIRES r1 YTAR FROM DATA: ,ISSUFSD
<br /> (Complete in Triplicate)
<br /> Application is hereby made,to San Joaquin County fora permit to`ior truci and ein/or install the work herdescribed. This
<br /> application is made in compliance vith.+San.Joaquin County'
<br /> OrdinanceFNot=51+9 and':1862 and the•Rules and Regulations of San
<br /> Joaquin County Public Health Services...,. ,. ,. +:. 7r,
<br /> JobAddress =Kpt;r. ° City'P Se* d6F' ' Lot Size/Acreage
<br /> �
<br /> Owner's Name -4—e,1flf1 tote• Address Phone �� 3S
<br /> + i�: �
<br /> Contractor /arfL !Ny1f J ddress.'. " f� �( Phone � Q
<br /> -'"License Nti. - " _
<br /> t TYPE OF WELL/PUMP: _. . ..NEW WELL ❑- .---WELL,REPLAC EME NT_Cl-_ —DESTRUCTION PLout of Service'Nei3 6>?4
<br /> PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER ❑ Mo _.
<br /> of.
<br /> Well C�
<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 /> 0 Industrial ~
<br /> Manteca
<br /> Dia: of Well Excavation. E I '
<br /> Dia. of Weli Casing
<br /> f7
<br /> Domestic/Private- - 11-Gravel Pack-r - L-0-Tracy.---t- - Type•of-Gasing-:: � -�+-- - -- -Specifications -
<br /> €"1 Public !a Other I r.' f I LL
<br /> f 1 Delta De th o Grout Seals
<br /> ..�._.�_..,,.�_,�_; p...a.�..:�,.,-�-.�,:..a..,_..�..,.,..__ I Type of Grout
<br /> I # Irri ation pP P ~f` 'Surface Seal installed by '—T- TT��
<br /> 0' A rox. De th" € I Eastern'
<br /> Repair Work Done - .0, TYPa of•Pump-
<br /> - StatetWork Do,
<br /> Well Destruction Well Diameter Sealing Materiel & Depth +` art,
<br /> DepthT ' �FS11er;Mst leI-&-Depth
<br /> TYPE OF SEPTIC WORK; -NEW,INSTALLATION l I •REPAIRLA-DDITION-(4_--DESTRUCTIONA I-HNo septic system permitted if public sewer-is, -* r
<br /> _ ? I available within 200.feet,I
<br /> Installation will serve: -Residence"_'`C0mmerc4all_0 her -t - -r- - -- ---- •- -
<br /> Number of living units:. Number of bedrooms
<br /> i
<br /> Character of soil to a depth of 3 feed: Water table depth I 1 €
<br /> SEPTIC TANK ❑ ' Type/Mig- -i- +� `. w �r -'Capacity" *_ `.'._ ""..Na"Corripartments�,
<br /> _a..
<br /> PKG. TREATMENT PLT, ❑ -_. -.0 ;;,_ ` . N Method bf Disposal.-
<br /> Distance to nearest: Well FoundationProperty Line
<br /> LEACHING LINE ❑ No. & Length of lines Total length/size
<br /> i FILTER BED -1n Distance to nearest: :Well Foundation I ,Property Line
<br /> „_ ,•
<br /> SEEPAGE PITS € I Depth Srre l�� Humber
<br /> SUMPS -
<br /> (l • Dist nce'to nearest t � Property Line
<br /> DISPOSAL PONDS
<br /> Well
<br /> Foundation
<br /> I hereby certify that I have prepared this application and that the wo-rk will be,done.in•accordance,with
<br /> 5 Joaquin county ordinances,state laws, and
<br /> rules and regulations of the San Joaquin County an ;
<br /> Home owner or licensed agent's signature certifies the folltawing.',"l.certify that in the performanca',of the.work:_for,which this permit is issued, I shall not I
<br /> employ any person in such manner as to become subject to workman's compensation laws;of California." Contractor's hiring or sub-contracting signature
<br /> certifies the following: 'I certify that in the pertorrrian_ce'of the,work for w_ hich this permit,is.issued,.I-sAail employ.persana subject to.workman's compensa -
<br /> tion laws of Califo .' I
<br /> The applica st;call for ail requir d inspect' s.-Complete draw' on-ravrse side,. - �; --•r-- -' - - _
<br /> Signed �
<br /> + ills: - Date: fir— t
<br /> _. r, - - J- FOR PART.MENY USE-ONLY
<br /> I
<br /> Application Accepted by I .Date �.
<br /> - a -
<br /> Pit or Grout Inspection by Date _-FineUnspection_b Dated
<br /> i i
<br /> Additional Comments:
<br /> Services JoaquinSan County -
<br /> Applicant - Rattan s11 copies to' Services, Environmental Healthblic tPer4t u vices"
<br /> 1601 eltan Ave.,,? 0 sax 2009, Stockton, 'CA :95201
<br /> FIE
<br /> Y
<br /> INFO AMOUNT DUE AMOl1NT REMIT 1 ED CA RECEIVED BY DATE. >'ERMIT'NO.
<br /> 4 EH 13-24 4REV.t R 51
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