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APPLICATION FOR PBRM1T <br /> SAN JOAQUIN COUNTY PUBLIC ELEALTH SERVICT .1"Em E` I V <br /> ENVIRONMENTAL HEALTH DIVISION o L <br /> 1601 E. HAZELTON AVE- PHONE (209)468-3420 QU 6 2 7 T70 <br /> P 0 BO% 2009, -STQCKTQN,. .CA 95201. <br /> E,NVIRONME ,AL HEALTH <br /> (Complete in'Triplicate) PERM!TlSLERVICES <br /> ' <br /> Application is hereby made to Sea Joaquin'County for a permit to construct and/or install the work herein described. This <br /> Joaquin Counttyy made in Public H <br /> _% application ealth.alplieoca v.th- Ban Joaquii:t County Orthe Rules and Re <br /> i9ervices. <br /> dinance No. 549 "d. 1862 and gulatione.of San <br /> . . - <br /> r Job Address /140 <br /> T City i,+„v Lot 31ze/Acreage <br /> ..R•x:tar-:s fUsme r. � �• tf,1^V �� - ......�..Y. <br /> �t. Address .— .r1pf 1` f` <br /> Phone - G 3' I a :Fi <br /> Canlract4r,�Q� ', -mace ddress tj <br /> " rV �. ^ <br /> �" ,Crlricense Na. !r t Phone � <br /> TYPE.OF.,WEE L/PUMP NEW,WELL P.:. WELL REPLACEMENT I] DESTRUCT IDN Cl Out of Service troll Cl <br /> ys PUMP INSTALLATION 0, SY$TE'M REPAIR 0 OTHER O Ronitoring Nell <br /> DISTANCE TO NEAREST''SEPTIC TANK'. SEWER LINES <br /> AGRICULTURE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ULTURE WELL _ <br /> INTENDED USE TOTHER WELL <br /> PITS/SUMPS <br /> YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1.1 Industrial © Open Bottom 0 Manteca pia, of WeN Excavation <br /> Domestic/Private Cl Gravel Pack Dia. of Well Casing <br /> L7 Tracy Type of Casing__ Specifications <br /> VI Public [.1 Other n Delta Depth.of Grout Seal _- <br /> Type of Growl <br /> Irrigation Approxi Depth I i l.asra(n <br /> ' SuripCar Soul installed by_._...,� <br /> Repan U <br /> Work Done . .type of.Pump H.P. <br /> Well Destruction C7 Well Diameter State Work Done <br /> Sealing Material & Depth <br /> F <br /> Depth !Piller Material.ii Depth <br /> TYPg OF SEPTIC WORK :;.NE►N.IN.$TALLATION I ! :REPi41H/AD pITION I 1 <br /> DES.TROCTION Il lNo septics stony ermiftgd if public sower is, <br /> Installation will®erne Reside availablwithin 200 feel.) <br /> �d �,L <br /> r►ce 3 -Cornmercla3 -�other <br /> Number of living,units: Number of bedrooms—�� u <br /> Character of ttoil to s depth of 3-(".t..' <br /> SEPTIC TANK W -Type/Mf@ Water table depth <br /> PIcG. TREATMENT PLT;C} Capaci;y�_ . No. Compartments <br /> �* rMethod of Disposal <br /> Distance to Hearse; Well Foundation <br /> Property Line <br /> Fq LEACHING LINE ('"o. & Length of lines 3 <br /> Total long[ <br /> FILTER BED ' <br /> Q Distance to nearest: Weil Foundation <br /> --- Property Line <br /> SEEPAGE PITS 11 Depth Sire <br /> Number <br /> SUMPS <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS © Property Line <br /> �I hereby ce}rtrty'that I have piepared this application and that the wo{k witi,be done in accordance with San Joaquin county ordinances, stela taws, ,end <br /> rules artd lggpla6ona of the Son Joaqujn'County <br /> Horne owner or,lrcensed agent's signaturegdrtifies the following:'"I Certify that in the performance of the work for which this permit is issued, 1 shall not <br /> amploy any person in hush m4nnitr a<i to become subjagt to workman's Compenuation laws of California." Cnntractor'a hiring or sub-contracting signature <br /> certifies the following: I certify that in the performance of the work for whir..h this permit is issued, !shall®m 10 <br /> tlgn lavr6 t7€Cafifprnle employ persons aubjgct:awgrkrnan's camipensa. x_ <br /> A <br /> Tha:spplicant mus! call for aN roquired inspection; Complete drawing on rovers* side. <br /> r S+goad Title: <br /> ate ° Date: 2��� _C----F. FENT USE ONLY <br /> Application Accepted by <br /> z.. Data Area <br /> Pit or Grout inspection by. Dateq <br /> — Final inspection by Date..".L—Z_�0 <br /> Additionsl,.Ccfmmenta: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, lRrivironmental Health Permit/Services 1 <br /> 1601 E. Aaselton Ave.. P 0 Boz 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED 9Y DATE PERMIT'NO. <br /> E".13-24.f REv.I/M 5! <br /> 71641- f v <br />