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APPLICATION FOR PERMIT <br /> 41ECEIVED <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. PHONE (209)468-3420 J Ut 2 7 1990 <br /> P O BOX 2009, 8m6CKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> PERMIT- DATE I PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby made.to San IoahulsnanCJoaquin <br /> uinoCounr a ty ordinancermit to No. 549 and struct o1862 and the r instal.1 eRules work hand eRegulatlonin aoi Sens <br /> application is made in compliance /' <br /> Joaquin County Public Health Servicee. / <br /> of Size/Acreage <br /> Job Address f� <br /> Owner's mo <br /> s N� - <br /> �f /lt' V r /Address Phone <br /> C_ t1 (actor // Wdesst r IcenseNo UU/ Phone <br /> service Well <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEME T ❑ DESTRUCTION O Out Monitoring Well Ll <br /> PUMP INSTALLATIOf>< SYSTEM REPAIR O OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 0 <br /> _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> �4msstic/Private O Gravel Pack O Tracy Type of Grout <br /> I I'l Public Ci Other n Delta Depth of Grout Sea�i' <br /> I I Inigation Approx.�Dep h I Eastern ,S (face Soul'Ins�llid by at on ml S <br /> Repair Work Done D Type of Pump H.P. r <br /> Well Destruction ❑ Well Diame Sealing Material;. Depth O <br /> 14 <br /> Filler Materiel 'De➢ih <br /> Depth <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION( I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> < j available within 200 feet-1 <br /> r ' <br /> Installation will serve: Residence r Com ercial -Other," •`�'` `�''' <br /> f <br /> FE <br /> Number of living units: � �Number of bedrooms <br /> Charactai of soil to a depth-of 1feev, ` - - - � 'Water table depth Q <br /> _.:. Q <br /> SEPTIC TANK ,r0 � Type/Mfg, Capacity �/fVo. Compartments <br /> j Method of Disposal <br /> f PKG. TREATMENT PLT:-E) + f k F <br /> (, Distance to nearest: Well Foundation ? Property line <br /> LEACHING LINE ,O No.B Legh of tines '' •; t 7�j Total length/size R <br /> FILTER BED D Distanceyto nearest: Well Tourldation �'^ Property_Line <br /> ` SEEPAGE PITS 11 1 Depth f Size Number •� , <br /> SUMPS is s Distance'to nearest: Well "�° -Foundation' Property Line <br /> I DISPOSAL PONDS ❑ t#• <br /> F 1 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 /> Homeowner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner n to become subject to.workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> l N` certifig�the following:"I certify that in the performance_of.the work_for which this permit is issued�l'shali employ persons subject to workman's compensa- <br /> r xx.hon laws of California," 99 <br /> ? The app"ca t call or t r quired inspections. Complete drawing on rev side <br /> Q� Date: <br /> Sig d X �`' Till <br /> FO DEPARTMENT' USE ONLY <br /> Application Accepted by i Date �tL� Area <br /> } Z Z* / <br /> Pit or Grout ins Date Final Inspection by �' Date <br /> Inspection by <br /> Additional Comments: <br /> I, Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REM=CKRECEIVED BY EDATE PERMIT'ND, <br /> INFO G %�EH 13-211nEV.IIN SI O � <br /> EH ii-2E <br />