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Y s <br /> z yam, <br /> �e <br /> APPLICATION FOR PFMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL MLTH DIVISION <br /> 1601 E. WELTON AVE., PHONE 095201 2420 <br /> P 0 BOX 2009, ST=TON, (2 <br /> (Complete in Triplicate) <br /> Applicatiaa is he satde,%O [ism Joaquin County forpermit to Construct and/or inatsll the work herein described. This <br /> ppUcatlea is e3e Sa �,s <br /> Ca11anee ti7th San Joaquin Caanty Ordinance No. 549 szsd 1862 and the Rules and RegulAt1ona of Sam <br /> Jowle countr Pubitc Health Services. <br /> QOLo <br /> ty Cit OC t 91zelAcreege <br /> Job Address <br /> Phan <br /> Oyrner'a Nana ' U Address Q/(p <br /> �y U R1g1 Address RE�' <br /> s7• oS4V J-P.e License No. f<� �� Phone "2 ;' <br /> ConUaclor DESTRUCTION ❑Out of Service Me11 ❑ <br /> WELL REpaCEMENT ❑ }Iopitoring VeLL ❑ <br /> TYPE OF WELL/PLIMP: NEW WELL❑ SYSTEM REPAIR ❑ OTHER f9' <br /> PUMP INSTAI.LATION ❑ <br /> SEWER LINES �� DESP05!1L fLD. PROP.LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHi.t».LL PITS/SUMPS <br /> FOUNDATION <br /> ' iNTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> Dia.of Well Excavation <br /> ❑Industrial ❑Open Open L7 Manteca <br /> Type of Casing Specifications <br /> C1 Domaatiolptivate ❑Gravel Pack ❑Tracy Type of Grou �a° 0A T <br /> n Other C•f Delta Depth al Grout Sea <br /> ['I Public Sudscs Soul Installed by <br /> I I Irrrpatrort .� <br /> Approx.Depth I 1 Eastern State Work Done <br /> Ropair Wok Done 0 Type of Pump H.P. <br /> •-'_ li <br /> gaaag Material i Depth <br /> Wald Destruction ❑ well Diameter <br /> ,.� J Tiller lsatersal b I>eptiti <br /> .S•a/c yAJNOs.�r [I'I Degth�, <br /> TYPE OF SEPTIC WORK: NEW INSTALLA7lON E I REPAtR7A001TION t 1 DESTRUCTION l i-IN.aaabiparcwlsh�R 2�'rrrimled d pub!c sower ra <br /> ost.I <br /> InstsUWn will serve: Residence— Commercial— Other. <br /> Nurlsbor of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 foot: No.Compartments <br /> SEPTIC TANK <br /> E3 Type/Mfg Capacity—�� <br /> Method of 015pasal <br /> PKG.TREATMENTP47.Q Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> Distance <br /> LEACHING LINE ❑ 8 Length of tinea Property Line <br /> FILTER 13ED ❑ istsnce to rssaraat: Wall Foundation a <br /> size Number <br /> SEEPAGE PITS 11 D.ptn Foundation Property Lina <br /> ... SUMPS LI f}iatarlce to learnt: Well <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that d have prepared this application and that the walk will be dors in accordance with San Joaquin county ordinances,sate taws,and <br /> rules and regulations of the San Jasquin County <br /> Home owner or licensed 8961111's signs sonifies the tcuowing:"l certify that in the performance of the work far which this pemxt Is issued,d she 11 hot <br /> ion <br /> lactt"O signature <br /> =ploy any person in suchmom that in the enure sublet the <br /> wok for which%his tpermitisiossued.f I shall employ persons subject Io workrs hirring or tman's Compania- <br /> C"As the fallowing:" <br /> tion laws of Califofnta:' <br /> — The applicant must ail ter an required inspections.Compate drawing on ravens aide. 9 <br /> Tida: h,L,�. o -0Dais:Dais: <br /> --- <br /> --SIR r ---- - --_-- <br /> _ FOR 0EPARTMENT USE ONLY <br /> Dais Area <br /> Appkmoars Accepted by <br /> Date <br /> Pk cr Grout tnapection by — <br /> Final inspection by Data <br /> AddMbnl Comments: <br /> App]swat- Return all oopieo tog. Sea Joaquin County Public Health <br /> services, Emaronmaptal Health Permit/Sarvices <br /> .r 1101 lZ. Haseltrm Ave- F 0 Box 2009- Stockton. CA 95201 <br /> FEE AMOUNT DILE AMOUNT REMITTED CASH �.4.lpt.CEIVIEV 1*1 LATE PERMIT'NO.. ' <br /> INFO <br /> �' EN 152E IafV.IiRel ,y� � ' <br /> ,y <br />