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APPL I CA'T I ON FOR PERI[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> RNV I RONYMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 55201 <br /> PjIT EXPIRES I YEAR FROMDATEISSUED <br /> (Complete in Triplicate) <br /> ApplSCatLoa 16 heret)r sade,to Sea Juesuin County for aea permit to construct aadlcr install the vont herein deeof Sellas <br /> spplication i■ made is coopliaace %lith SJoa4uin County Ordirsance No. 549 and 1962 and the Rules sad Regulations <br /> Joaquin County Pualle Health Serri;es. <br /> I J City -Aj f.at Slye/Acreaae <br /> Job Address <br /> Owrssr•S NArres •r,C�/ <br /> ,*U E�'jftjaik�_ Address kr � Phone <br /> � i <br /> i ContedCtdt ��- r Address IPO !cense N Phone <br /> r TYPE Of WELL/PUMP; NEW WELL. ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ out or Service Reil ❑ I <br /> PUMP INSTALLATION D SYSTEMREPAIR ❑ OTHER ❑ Monitoring Well p i , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE I <br /> FOUNDATION AURICVLTURE WELL _ OTHER WELL PIT5ISUMPS: <br /> INTENDED USE TYPE OF WELL PRO6LEts1 AREA, CONSTRU_CTIDt4 SPECIFICATIONS-- <br /> Dia, or wait C..: >11 <br /> t C}lndustnsl. ❑ Open Bottorn ❑Manteca Dia- of Wel!Excavelion_ !`B <br /> s l7�Domest elPrivate ❑ Gravel Patkl ❑Tsacy Type of Casing 5pec;freatwns <br /> i'1 Prtboc 171 Other 11 Datta Depth of Grout Seal Type o} Grow <br /> fJ 1 IrriiStion —Approx. Depth I I Easton _ Surlaca Sews lnstaftad fay ' <br /> Aepir worst Doers L3 Type at Funsp H.P. Stats Work DormSC&L __ -�+- -•— <br /> We"D1i=ruCtidn ❑ Wall piMYtl1 ?---' 1iS IMtfsla� a Depth <br /> Dppt t i .r linMaterial aferial a Dajpth <br /> TYPE OF SEPTIC WORK: fi1EW • <br /> INSTALLATION ,REPAIRIADDITION i I DESTRUCTION I 1 iNO septic system Permined it public sewer q <br /> r available within 200!fret.) <br /> Irmiallation will eervt: Re+fiWrlOe,l�. COrtirlsarcial.� OC11ar�� <br /> Number of living units: <br /> p+ Nurrrbef of blafltaoms ~� <br /> ChNSCter Of ao►1 to s depth 01 3 fMd: r, - _ Wever table depth <br /> a <br /> SEPTIC TANK ❑ TyprlAMy !f� .! . 4 Capscit: No. Cwnparirnenta <br /> ;�� <br /> " PKG,_TRE1kT.MENT-PLT-0- I • Method Of Diapoaat�� <br /> i r <br /> Distance to n"nW: Well <br /> Ftxxtdal tide, �T Property Line <br /> ' LEACHING LINE 1�, No. 8 L-trf`igth w rink, fatal iangthlaixe <br /> I FILTER BED ❑ Distance to nersr�it; yyd'lA7 ��Faundstion property tine <br /> SEEPAGE FITS I 1 Depth Sisa Number <br /> SL7MF5 ;ll!!_ Distance to neareet:� WON/"�F� vundttian fid Aroperty� Li - <br /> ! �pi5pO5AL PONDS^ Cl:- , �,. t i ` '�'' <br /> L I hereby Cerlity lhat I have pespered this application and ghalf641hl-be done in-accordance with San,Jdaquin`cpunty ordinartcas,state laws, and <br /> rules end repufatkm of tMs San Joaquin county _ r <br /> Kwm owner W konsed spear's s4noture centifws the fntlowing: mce"I C@fWY that in the perforanof the work for whiot+':this permit is issued. t Shall not <br /> onM)oy any parson in such manner an to bacon%subpci,ap.worstme-wrr tsttfpensalion laws of California-"Contrs,60f;8 hiring or sub canusctlnp aignarure <br /> oaftiliea the to"winy: 1 Canty that in the peAosmancr-of-the work for which'this parmirls-is ued:!'+l'+all'ess+PloY Peresris subject to workman's compenaa• <br /> of Cil1?on'da.• � i <br /> The appfkant moat Ceti dr al in tions. Complete drawing on rebels!side_ } + <br /> a —. <br /> _ Signed ' TttaF�_ Date: <br /> FOR70 ; R fF r3NLY <br /> Date <br />€€€` AAAA+tion AeCepted by <br />! Ph or Grout inspection by } Dais Final Inspection by e <br /> Addit a"I Cvnwrtartts: <br /> t Applicant - Return all copies to: San Joaquin Coutstp Public Health Services �_��4- .__ -•- _. <br /> 1 _., -�,. •...�- .-, M.. .-. J Bnviroamebtsl Health p$rn'it�9ervSces _ _.- - <br /> __ - { --445•N -San Jon4UiA, P-0-Box 0009 Stkti;-CA 95201 <br /> { <br /> FEE R NT WE 1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMr7 Na. <br /> tM rale . <br />