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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ` <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 8.4 HAZELTON AVE. , PHONE ;,(209)46i8�-34201 {P d BOX 2009, STOCKTON, ICA 95201 <br /> { t A <br /> T 8%PIFtES 1 YEAR nQM DATES �SSC�En At1� <br /> (complete in Triplicate) iV VIROPj <br /> a <br /> Application ie hereby made.to San Jaagstiit Cdunty for a permit to constructand/or 3ueta1l tt $. ,[_,�,� <br /> appiicntioa is tmae fn ca�pliauuct with Sou J 'tuM exg3p d'este l is <br /> oat3uin county Ordinance No. S1+9'and 1862 artd the Rue atui<i: e$v6t ,of Sart <br /> Joaquin rrauat�yjPu�b2lc.:liealth services. �a <br /> Job Address <br /> City Lot 81ze/Acreage. <br /> Owners:,Name<- 01. L-13/�1tf Aildrass RIS,7 Phrfne <br /> Conirdt:tor <br /> TkP!~;C1f WELL/PUMP,: NEW WELL 0 WELL REPLACEMENT 0 DESTR7JCTl0 .0Out:Of'Service Veil Q <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C]* OT"ER: ritoring Well � <br /> ,y 5 aJ.: cst�l.v .roe,E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER.:i C3'tSPOSA;L FLD;—.J+ OP. LINE + <br /> PfIUNDATION. .AGRICULTURE WELL ()THEE(Yi7Ei L. <br /> INrENDED.IJSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. <br /> L'# industrial 0 Open Sotto O Manteca Dia,of Well Excavation 1"lia. of.Well P": . <br /> CI I IomestiClPrlvate L7 Gravel Pack GJ Bracy Type;o#Casing SciMcations <br /> i'1 Public n other. ri Delta Depth of Grout Seat ! v a#Grat <br /> I I Irfl ation <br /> .. g1:1Eastern. Surface,Seal Installed by <br /> Repair Work Dona C3: Type of Pump . M.P. State Wark Rorie <br /> 99 <br /> ..r. . <br /> Wall DesiructiorE Id.: Well Oiarttetet. - 3ea]:3.ttB Material & Depth «} <br /> Depth Filler Material 6 Depth 9F <br /> TYPE Gil: SEPTIC WORK: NEW INS <br /> TALLATiON t I REPAIR/ADDITION I i bESTRUCTiON C t iNa septic system permitted if public sewer is . <br /> available withln feetA. <br /> Installation will sorve> Residence Commereist_ Other <br /> Number of living units. — Number of bedrooms <br /> Character of soli too depth Of 3 feat: tl <br /> Water table depth <br /> SEPTIC TANK Q Type/Mfg Capacity l No. Compartments <br /> PKG. TREATMENT PLTi CI Method of Disposal <br /> Distance to nearest- Well Foundation It Property Line <br /> LEACHING LINE 0 No. &Length of lines Tr tai lengthlsize <br /> FILTER SED 0 Distance to nearest: Well Foundation--1—'Property tine <br /> SEEPAGE PITS t ! Depth Sire Number # <br /> SUMPS L1 Distance.:to nearest: Well Foundation- i Property Line <br /> DISPOSAL PONDS 0 I . <br /> i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state taws;and <br /> rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performs of the work for which this permit is issued;l shaft 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 foaawing:>"I certify that in the performance of the work for which this permit is issusd,l ohail employ perscns.subiact:to workmain's compensa- <br /> tion laws..af Callfo la:'• ~"'� i� <br /> The applicant mu= call f all required inspections. Co tete drraaw�' p on roviirse side. t riLsc4 <br /> Signed <br /> Title: <br /> 3,eJ <br /> - FOR ttEPARTMENT USE ONLY aP <br /> Application Accepted by. : Date,, ' <br /> Acres... �_____ <br /> Pit or Grout Iris coon / <br /> blr... Hate "_�, /Final Inspection tY ".( ....,1 LBts " <br /> Additional Comments.. 'E <br /> Applicata: - 2tetttrn:all copies:to. San Joaquin County public Health <br /> Seryiaerty knvirommental. Health Permit/Services <br /> z661 z.. on Ave., F 0 Bax 2009. Stockton. CA 95201 <br /> FEE AMOUNT iStJt"s:. AMOUNTAE-MiTTED CK i <br /> INFO CASH RECEIVED"8Y DATE AERMI'f`NO: <br />� EM13-2XittEy.izn�i �y + <br /> EH;rH 1 / <br />