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N APPLICATION FOR PERMIT TH SAN JOAQUIN COUNTY PUBLIC DIV S ON SERVICES faletL ENVIRONMENTAL KTON, CA 95201 pyo BOX 2009, STOC 249.) 46$3447 ' A - (complete In TI'IpliCate) , uin County for a Pe mit to construct and/or install the vlee herein described. This Application is hereby Iaade to San Joaq Joaquin County Ordinance No. 5k+9 and 1$62 and the Rules and Regulations of Ban Bance with San Joaq + application is made in cow f „tom Joaquin County public Health Services, Lot Size/Acreage City 'e ,. � • -��2 -903 E' Jd4 Addfasa �� 'GR.: !`� Phone Address 0 Owner's Name License No. 00 f Phone �2 7 2 H put of Service Well ❑ f�rl9 Address DESTRUCTION ❑ Well Contractor L WELL REPLACEMENT ❑ Monitoring NEW WELL' OTHER. ❑ 'TYPE OF WELLIPUMP:. SY57EM.REPAIR ❑_ _ .. PROP. LINE �-� PUMP,INSTALLATION_Cr DISPOSAL FLD.� 2 • .: -_=�---� 'F` SEWER LINES--� PIT5ISUMPS DISTANCE TO NEAREST: SEPTIC TANK OTHER WELLI�--- fEPTIC T ION �, AGRICULTURE WELL 1- r PROBLEM AREA CONSTRUCTION SPECIfICAT10NS5, TYPE OF WELL ry --- D'a-ofrWaiPCasing INTENDED USE aStom "Wg❑-Man- ca---,••4pie.�of=WethExcevatio- k. Specifications C_� IndtTit7iah1- 47 Tracy7Ype ot'Casing D r �, `e Type of Grouter �� T '~ U Domestic!Private ❑ Gravel Pack Depth of Grout Seal . CI Other ❑ Delta rL M P,Ib6c, — Surface Seal Installed by �� 2,5_.APprok. Depth ❑ Eastern Stale Work Done r �wd'tfriflauon H.P. Depth i Type of Pump Sealing Material h Dep '* Repair Work Done U F Weil Destruction O Well Diameter ----- Filler Material h Depth �J E Depth ,C p4i4 available within,200 feet) "t TYPE OF SO ` IC WORK: NEW INSTALLATION 1] REPAIR/ADDITlON II DESTRUCTION Gl fNo septic system permitted if public sewer is * Commercial_ Other Installation will serve: Residence N.,, - at;living units: Number of bedrooms, �.— ---Water-table depth. Character of.soil to a depth of 3 feet.- _�,�. Capacity—. No. Compartments }.. SEPTIC TANK ` ❑ TypilMlg k Method,*( Disposal --li-PKG. TREATMENT.PLT. 0 Foundation __ — Property tl Y Ristance to-nearest: Well ��._ Total length/size -� LEACHING LINE Cl No. S Length of lines Foundation �----�- Property Line �I Distance to nearest Weft------ FILTER BED :1 Number t 1 1 Depth Sire— Property Line SEEPAGE PITS Foundation + SUMPS,_ Ll Distance to nearest: �1 , Wall�— •_-� DISPOSAL PONDS ❑ } f that I have prepared this application and that the work will be done in accordance with San Joaquin county ls rarm'IlCssssued, I sale heet notes F I hereby card Y rules and regulations of the Sart Joaquin County g• „ Home owner or licensed agent's signature Certifies the fl Cowin i certify that In the performance of the work for whichsons subject to workman's compensa ation 1 employ any person in such manner as to become subje of to warkafor which ethis permit laws s issued, I shall smp^tYaPe r'a hiring ar sub-Contracting signature. certifier the following: "!certify that in the pertnr manceI tion laws of California." t The applicant mutt all for all re wired in clions. Complete drawing on reverse side. Date. I__7 : Cl Signed Title OR..DEPART•MENT.USE ONLY- �- - r = � Data Area Application Accepted by Date Date "f Pit or sou Inspection by� final lnapection by -- , Additional Comments. JOAQUIN COUNTY T,� RVICES Applicant ' Return al?'coples to: SENNVVIRONMENTAL HEALTH UDIVISION pERMBLIC HEALTH IT/SERVICES \Q� • 445 N SAN JOAQUIN, p O SOX 2009, STOCKTON, CA 95201 GK RECEIVED BY DATE PERMIT'NO. FEE i AMOUNT DUE AMOUNT REMIT"fEO CASH INFO r . } . EH 13-24 IREV.I/h Sl CA tV10 i 'JH 11.26