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-�,-d .._- APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC -HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION f 1601 E. HAZELTON AVE. , PHONE (209)468-3420 �. P O BOR 2009, STOCKTON, CA 95201 F;gP RES 1 YAR EFROM DATE (Complete in Triplicate) f Thi taU work in described. I Application is hereby made to San lith San County or a permit to county ordinancenstruct No. 549 ando1862sand theeRules a.ndeRegulations of Sans application is made in compliance with San Joaq Y Joaquin County Public Health Services. ZO q a Lot Size/Acreage C City 11 Job Address C1 L� 3 Phone tS� inJ Address -,Z' Owner's Name ' -- I (p t License No. �J' 2- Phone 7�2,,- 9�7 rAddtess Contractor pR{�C-�lpN E^� -of-Service-We 11= ❑ , EI-L REPT ENT" ._. __—.. l�nnitoxirig Well• L3 TYPEAF_WELLI.P_U-MP- .�--» SYSTEM REPAIR ❑ OTHER ❑ -k--T- �-"" PUMP INSTALLATION Cl '200' SEWER LINES -- DISPOSAL FLD O PROP. LINE k DISTANCE TO NEAREST: SEPTIC TANK 'r�� PITS/SUMPS 7�'- FOUNDATION 5 AGRICULTURE WELL � OTHER WELL I u PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL Dia, of Well Casing f C7 Industrial. Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 3r6 C] Tracy Type of Casing D — om ❑ Grave! Pack Ile TYPa of Grout Cl Other i� Delta Depth of Grout Seal i"1 Publics _ '35' pprox. Depth l 1 Eastern Surface Seal Installed by - 11 Irrigation State Work Done — Repair Work Done ❑ Type of Pump H.P. Sealing Material 6 Depth I' Well.Destruction 0 Well Diameter Filler Materiel & Depth i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION i I availabllelc system w thin 200 feet.) if public se r is "j I Installation will serve:-.;.Residence Commercial — Other Number of living units: Number of bedrooms Water table depth ' Character of soil to a depth of 3 feet: F�\� acity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal +� PKG.TREATMENT PLT. ❑ I. Property Line \tel Distance to nearest: Well Foundation - r l'otal'1e�i�thYsize'-�� - LEACHING LINE ❑ No. & Length of Ii `FILTER�BED Cl Distance to n est: Well Fo�atidn Number SEEPAGE PITS I 1 Dept Size SUMPS LI Di ante to nearest: Well / Foundation Property Line i DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that'the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the to "I certify that in the performance a#the work for which this permit is issued k I shall not _ employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature T certifies the following: "I certify that in the peAormence of the work far which this permit is issued, I shall employ persons subject to workman's compansa- I tion laws of Califor ta. The$pplicant m t II for all r d inspec ons. a drawing on reverse rde. s �®` a 4 Date: Title: armor Signed 11 FOR DEPARTMENT USE ONLY f 1 ' v. i '• +`'° �a �l 'Z ��'0 Area 3t ;_. +�.-. % �---•�--_...�._. �: �,Data _ Application Accepted by i Grout nspection A - { `TDate� - Final Inspection by Pit or Date r ''- 0 Additional Comments: - Applicant - Return all copies to: Ban Joaquin County Public Health a Servi669;Environmental Health Permit/SeT-vices k 1601 E-.,Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 5 CxPERM11 N0. FEE AMOUNT DUE -,- ---AMOUNT'REMlTTED CASH RECEIVED (!Y DATE = INFO_ _ E . EH 13-24 IREV.i I N sl ! EH 14.26 $