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' APPLICATION FOR PERMIT D. 3 R4E <br /> SAN JOAQ ENVIRONMENTALIN OUNTIiRY PLALTSIC �DIVISION ALTH SERVICES .pli <br /> 3 601 E.P �g'2009 AVE. ,TON STOCKTONI, CA095201T3420 All G <br /> PERMIT gMXRFS 1 YEAR fROM PATILISSUM) ENVIRONMENTAL,HEALTH <br /> (Complete in Triplicate) PERMITYSERVICES <br /> Application is hereby made,tloi San Joaquin cSan ounty for aounpe 0 diaencenNo 5 9 ettd 1862 and the eRules and work eRegulationin sdof San <br /> is <br /> I application in made in comp <br /> Joaquin County Public Health <br /> SL-rvices. <br /> r I f N. .r' City �CX7nw Lot.Size/Acreage <br /> Job Address <br /> _ Address <br /> Owner's Name r 3 6 3 p�It 6G C114ej of-ra I TA B <j{ 6 - <br /> Contractor <br /> DR `t irN./r Address is C�ROCv G License i�o. .t/91.x8 Phone 6 S y s <br /> TYPE Of WELL/PUMP: ANEW WELL WELL REPLACEMENT C1DESTRUCTION Ll of Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK ��.. <br /> SEWER LINES r DISPOSAL FLO. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y // <br /> Ois. of Well Excavation <br /> ff Dia. of Well Casing G <br /> 0 Industrial ❑ Open Bottom ❑ Manteca __� — Specifications <br /> C} Domestic/Private Ll Gravel Pack ❑ Tracy Type of CasingDeltaof Grout Seal Type of Grouter NO A AaT <br /> Il Public [II Other J 11 Delta <br /> I I Irrigation Approx. Depth I I Eastern Surface Ser+l Installed by <br /> of Pump H.F. State Work Done <br /> Repair Work Dona U Type i Sealing Material A Depth <br /> y Well Destruction ❑ Well Diameter x <br /> Depth —II 7 — Filler Material 5 Depth �---�- <br /> ION t I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l i DESTRUCTa�ailab elrw within 20D lost.) <br /> led if public sewer is <br /> Installation will some: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK C3TypaYMf9 Capacity <br /> Ir Method of Disposal <br /> PKG. TREATMENT PLT. 1D Property Line <br /> Distance to nearest: Well Foundation <br /> if <br /> Total length/size <br /> LEACHING LINE C1 No. & Length of lines Property Line <br /> C FILTER BED ❑ Distahee to nearest: Well Foundation <br /> I <br /> Number <br /> Size <br /> SEEPAGE PITS I I DepthI Property Line <br /> If SUMPS LIDista ice to nearest: Well Foundation <br /> DISPOSAL PONDS <br /> ![ will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared.this application and that the work <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the fallowing: u certify that€n the performance of the work for which this permit is issued.I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus I! far all required ins tions. C plate drawing on reverse side. <br /> A/— <br /> Signed <br /> Title: -6�1/i �^ ?i S '�-- Date: <br /> w do 1Z <br /> FOR DEPARTMENT USE ONLY <br /> Data Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Finai Inspection by Date <br /> Additional Comments: ayd r <br /> Applicant - Return copies to: San Joaq County Public He h <br /> r Services, Environmental Health Permit Stockton,/Services �w <br /> I 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 d7J <br /> FEE GK EGEIVED 8Y DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED H <br /> INFO f]h 19N/3494/v <br /> CH 13.24 IREV.t/K51 6 <br /> 9r� 6glI,J�J lto I <br /> Cttt/JJJ t <br />