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APPLICATION FOR PERMIT } c <br /> SAN JOAQUIN COUNT' PUBLIC HEALTH SERVICES <br /> j ENVIRONMENTAL HEALTH. DIVISION <br /> :1601 E. HAZKLTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> PRAMTT EX—PIR FiS 1 YEAR FROK BATF: ISSUED <br /> (COmplete its Triplicate) <br /> AWllcation Is hereby =Lde,to Sari Joaquin County for a permit to construct and/or instal' the work herein described. This <br /> application is =de in ccaziiia.nnce with San Joaquin County Ordinance No. 549 and 1862 and the :tines and 'regulations of San <br /> Joaquin County Public Health Sezvicee, <br /> ,Sob Address � �r�ti�� � Cit" Lett Size/Acreage <br /> t3xner's Karn ,�.GJ �zress � d1/ Phone <br /> ­400 <br /> Cantratlot _ Address `=T :License No. Phone VI <br /> TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT DESTRJCTION _�] Cut of Service Well 0 <br /> PUMP INSTALLATION D SYSTEM REPAIR 0 OTHER Cl Nonit.orisig Well C7 � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. P-90P. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS:SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> %1 Industrial Oper,Bottom c.i Manteca Dia. of Walt EAcavat,on Oia. of Well Casing <br /> 17.1 Domestic lPrivate L-; Gravel Pack 0 Tracy Type of Casinq- Specifications <br /> r _ <br /> I'1 Public $ !i Otf�er n Oalta Depth of Grout Steal Type of Grout <br /> I lffijp2lion Approx,:Depth 1 1 Eastern Surface Sedl Installed by <br /> Repair Work Gone 0 T i <br /> Ype o1 Pump H.P. - Stara Work Dare _•_ <br /> Well Destruction 0 Well Diartleter Sealing Material i Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION . . REPAIRIADOITION DESTRUCTION 1 (No seprc system permitted ;i pi,biic sewer is <br /> f available within 200 feet.) <br /> Installation will serve: ftasidance Commercial,_„_,-,- Other� f <br /> Number of living units: -I— Number of adrooms <br /> Character of soil to a depth of 3 feet:I r4+". Water table depth <br /> SEPTIC TANK. © Type/Mtge Capacity i'Z, No. Compartments <br /> PKG, TREATMENT PLT. 0 f /�� Method of Disposal <br /> Distance to nearest: well..Cir u.�_ Foundation..-YO Property Line i <br /> LEACHING LINE L'k�Na. P. Length of lines Total length/size <br /> � .L� t <br /> FILTER BED , d Distance to nearest: Wali a8__ Foundation l Property Line ,,,2-0 I <br /> SEEPAGE PITS >L✓Dapth f ti Size 3 _. <br /> Size �: Number <br /> SUMPS LI Distance to nearest: Well 1 (3 Foundation �_ Propatty tine <br /> DISPOSAL PONDS -Ll• I <br /> I harabY certify that i have prepared this application and that the v+ork will be done in accordarnca with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner pr iicensad agant's signature comfiss the following: "I certify that in the pertormence of the work for which this permit is rssued, I shall not <br /> empioy any persO,in such manner as-to become subject to workman's compensation laws of.California."Contractor's hiring or sub-contracting signature <br /> certifiers the following:"l certify that in the pert&mance of the work tar which:his porm3t is iresued, 1 shall employ persona suoject to workman's compensa- <br /> tion laws of California. <br /> „ r <br /> The applicant must ail for all fsqulf9d ins tions. Complete drawing on reverse side. <br /> Signed ,I:::!z Title: fr1/L;'�'k�t'1 Date: <br /> t <br /> ,�,,.`` FOR DEPARTMENT USE ONLY G <br /> plicatioat Accepted by ` ��^ 1 ----1 -7 Area <br /> j�•-A `��,�� Data Area C- <br /> Pit�gt Grout Inspection byLi.� Data� r� �t a Final Inspection by���o Data t 4- <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health v <br /> Sem-icee, Rnvironmental Real-rh Permit/Serviaea <br /> 1601 E, Hazelton Ave., F 0 Box 2009, Stockton, CA 952,01 <br /> FEENCO AMOUNT DUE AMOUNT REAritTTED �" RECEIVED BY OATE PEAMiT NC. <br /> CASH <br /> fit 13.2a JAtV.i As; C t <br /> Ehi;4a!1 � 1 <br />