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APPLICATION FOR 1r61t111T <br />' SAN JOAQ111N 'OUNTY PUBLIC HEALTH SERVICESi•,. �' r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 AUG 0 1 5990 <br /> P O BOX 2009, STOCKTON, CA 95201 C�JVir2QN!��EIVTAL NEALjFi <br /> PEM IT EXTlR1sS 1 YIiAR FROM DATE ISSUED PERMIT/SERVICES <br /> (Cr—aplete in Triplicate) <br />■ <br /> Application is hereby made to San Joaquin County for • pewit to Construct and/or !Mull the work herein described. This <br /> application is made in compliance with San ,;Oaquin County Ordlnan-e No. 5L9 and 1862 " the Aides sod Regulations of Sam <br /> Joaquin County Public Health Services. <br /> Job Add-ass ��`'�Z?�_��- C•tv _ Cot 8lte/Acresae q�1 <br /> Owner'sl.s.S4. (.. _` 1 1 do ass Phone <br /> Phone 31 <br /> Nc <br /> Tv PE OF WELL:PUMP NEW WELL WELL REPLAL'14[NT DESTRUCTION Ll Out of Service ►ell <br /> LI <br /> PUMP INSTALLATIOfy�� SYSTEM RFPA�ti OTHER CitorleSg veil C <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES �_ DISPOSAL FLO. PM j,. vE i <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBIFM APFA CONSTRUCTION SPECtFICATION_S_ <br /> ` <br /> Industrial — f;Open Ronan i 1 Manteca Ora o1 lryelt Escavetron _ Dia.of Wait Casing <br /> 74�nashcrPh,rste ( i Gravel Pact l Tracy Tvve of CostngSP0014C8100M <br /> Pi,h"c Other , pens Depth of Grout Spat Typir of Grout��_ <br /> Inglahon Aptrn�r 11 y'1 ss ern ..$,idaee Seel Installed N <br /> Repair Work Done 11 Type of Pump P.P. ��1l�. —---— <br /> Well Destruction lJ Well Diameter �aliftg flaterlal S Lep'.h C •� 4� �J <br /> Depen __T ✓✓���Filler IEatertal S Depth <br /> TYPE OF SEPTIC WORK NEW:NSTAl1 ATION I I REPAIR•ADDITION I Dt Sl PLICTION I (No septic system petmrlted rl P"bC sewer is <br /> avarlabts wdfvn 200 feet l I^� <br /> Installation will so" Residence_ CofnmerUal _ Other <br /> Number of Irving units. _ Number of bedrooms <br /> 1 Chotacter of soil to a depth of 3 f _Warr SSW depth <br /> I <br /> SEPTIC TANK Cl Type/Mfg CWC-VY No.Co oot rn S <br /> PKG *!'CPTMENT PLT f.l method of Dilimpow <br /> Distance to nearest Wolf_ _ Foundation Property Lan• <br /> LEACHING%INE l I No. 8 Length of lines ..�_ -- »-�.— TOUI"th/ors <br /> FILTER BED I Dratanc•to nearest. Wap FounGten Property Line _ <br /> SEEPAGE PITS--- I I- Depth--- -- Sim _—. _-_ Number---— <br /> SUMPS Distance to nearest Wait Foundation — Property Line <br /> DISPOSAL PONDS 1: g <br /> 1 haraby candy that I hove pre, ad th-1 Apphcahon and that n,e"tk will be dun-in acCcrdance with San Joaquin County of m.state I•ars, '9 <br /> rulas and regulations or the San Joariurn empty <br /> Home owner or licensed agents signature catd.et the fonow,no '1 certify jr-at in rhe perrormance of the work for which f"p•rr W N rssu•d.I shall not t <br /> emplov any person in such manner as to become subject to wotsman s cnmpenaatiOn laws OI CJkrornia"Contractor's flrrMg W wD•Contfsctirq prgrtalWe <br /> 4: <br /> CMdNa IM following '1 ceridv brat in IM performance of the wor, rot w'+Kh this permit is issued.1 atoll empbY persons Wbletl to tMDrYRyn'•Cortlp•nY <br /> non laws of California" <br /> The appl,car M/�t/�Caa�lllJlf Q, all <br /> w mmpect.ont Complete drawrn on se sidp24�10 <br /> Signed 1 —_Ly 1� /^C.-l ct�J T tl•. .c o.S•. 7 l; � <br /> Y;? <br /> EPARTMENT USE ONLY4C <br /> ApplucahonAcceptedby _—_ - �1-'f.� Date Aral <br /> Pit or Grout Inspection by __ __- Date- _ Final Ins1»cnon Dy 0ita <br /> Additional Comments —_ --- -__ -- <br /> Appi'rant - Return all ropiee to: Bar J�ayuin Cuunty Public Health <br /> Services, E.ivironmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Bole 2009, Stwcvton. CA 952ul <br /> fat �NOt,vt Dui aMOI'Nr nFMTEb K rt[CHVED sv DATE aMM1T NO <br /> r.r0 --__ CASii j— <br /> ,� .>. -I-.--�-� <br />