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APPLICATION:FOR PERMIT � <br /> , <br /> SAN JOAQUIN COUNTY PUBLIC DIV SON SERVICESTH <br /> ; <br /> �VYgON1dENTAL ��* CA 85201 <br /> P 0 BOM 2009, STOCgTON, <br /> (209) 465-3447 <br /> Triplicate) 2S5'_2�U—fib f) <br /> (Complete is This <br /> for a Permitthe Rules rand Re�ylationa of San <br /> uia County t Ordinaacenito 549raartdo instal the work herein described. <br /> T <br /> s:to 13an Taaq uin Coca Y V1 <br /> Appllcatiea <br /> is hereby teed / .V! pow c.Q['r'PS <br /> application is me 1SeaHealth i3 rvices=. Sara ��� r�39 dr� �'nc.„ Lot Size/Acresae 1 <br /> Joaquin Couaty Pu Far 7jvaw Terv5121 � P City <br /> o No��� aa9-$3b-Job Address} Phone <br /> ! Address rAC <br /> Ci o� T{o c l five <br /> 0wner16 Nems 'C 4 tf !s3$' /ndus�rr'u fia�/, $'� Phone <br /> ['Ham !/ yrpq 3aSP C 5/ License No.J� <br /> Ex lO�b>ti �,n5evvr[C Address WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well p <br /> Contractor OTHER p ttcnitoring Well <br /> NEW WELL f7 SYSTEM REPAIR ❑ <br /> TYPE OF,WELLlPUMP: PROP. LINE <br /> I PUMP INSTALLATION p DISPOSAL FLD._.�---- <br /> SEWER LINESPtTSISUMPS <br /> -----�-^ OTHER WELL <br /> I DISTANCE TO NEAREST: SEPTIC TANK —��---' AGRICULTURE WELL �-- fr <br /> FOUNDATION — <br /> t <br /> f I C� mo PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia o1 Well Casing chs <br /> I INTENDED USE TYPE OF WELL <br /> ----�` Die, o1 Well Excavation r <br /> C] 0 n� p Manteca - ,yd 1 specifications <br /> ` n Industrial a/Tracy Type of Casing Type of Grout fi►s� �.�5 <br /> rave` Peck Depth of Grout Seal <br /> �;] Domestic/Private []Delta <br /> M Public I-1 01per I '70. Surteca Senl Installed by I rJ Iuityation Approx. Depth !1 Eastern State Work Done— <br /> Type of Pump H.P• t <br /> Repair Work Done U Sealing material 6 DePth <br /> Well Q,4ttyetttln ❑ Well Diameter �..—�— ]Piller No b Depth <br /> Depth rmitted if public sewer is <br /> TYPE OF EP WORK: NEW'INSTALIATION L] <br /> REPAIRrAD01TION L7 DESTRUCTION'E 1 avail blerwith n 200 feet.) <br /> IV/ <br /> I Installation will serve: Resrderl �- <br /> Comm,rcial _ Other .�----= <br /> I Number of living units: — Number of bedrooms Water table depth <br /> i Character of salt to a depth of 3 feet: CapatitY No. Compartments <br /> SEPTIC TANK O TypelMfg - `^n Method of Disposal <br /> PKG. TREATMENT PLT.0 i Foundation Property Line <br /> i Distance to nearest: Well �.— <br /> i <br /> Total length/ala <br /> LEACHING LINE Cl No. f! Length of lines Property Line �-�— <br /> Foundation <br /> — <br /> f I FILTER SED Cl Distance to nearest: Well , <br /> Sire Number <br /> SEEPAGE PITS 11 Depth -----�-- Property Line <br /> SUMPS <br /> CI I Distance to nearest: Well Foundation�.— <br /> i DISPOSAL PONDS <br /> 4 I hereby certify that I haus prepared this application and that the work will be done in aeCordanca with San Joaquin county ordinances, state laws, an <br /> [ rules and regutatione of the San Jogequin County „ <br /> Home owner or licensed agent's signature Certifies the following; L certify that in the performance Of enea f the work for whim this permit is issued, (than not <br /> t <br /> -employ any person in such manner as to become subject to workman's compensation taws of Celitornia."Contrecton,rsub ring et to workman�s comps sa <br /> certifills the totlowinq:"l certify that in the performance of the work for which this permit is issued. I shall employ ttP H <br /> t tion taws of California." raver side <br /> The eppl;eant m st call for all requ' in tions, Complete drawing 4Cr � r / (ag l.S f ' y7S/ Date: <br /> Signed X <br /> �• > — -- Title: KK <br /> FOR DEPARTMENT USE ONLY ` <br /> Data Area <br /> Application Accepted by Det, <br /> Dais Final Final Inspection by <br /> Pit o Grou Inspection by A _ <br /> Additional Comments: _ <br /> Applicaat - Return all Copies to: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION BLIC _DIVISION REMIIT/SETH RVICES <br /> 445 K SAN JOAQUIN, p 0 BOX 2000, STOCKTON. CA 05201 <br /> ArrtPUN7 REMITTED CK RECEIVED BY. REM <br /> INFOFEE AMOUNT DUE CASH <br /> . EN t�•7�Inev.rresi S .� 5 <br /> EM:l.re <br /> Ifs <br />