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' APPLICATION SAN JOAQUIN 'COUNTY"PUBLIC HEALTH SERVICESA�' q, r ENVIRONMENTAL HEALTH DIVISION CEJ1feD 445 N SAN. JOAQUIN,' PHONE (209)468-3420 a C r ®2 1992 P O BOX 2009', STOCKTON,' CA 95201 PUBLIC N JpAQUI _ HEqL�H SERVICcS . PERMIT EXPIRES in�Tri�pOl�ic DATE IS"§ �MFNTgj_N�q�.Ty�f{11Slvr�r Thi Application Se hereby made t0 San V hu��CJ q infor County Ordinanceconstruct No. 549&and"1$62 and thethe Rules endherein Regulationsdescribed. of Sans application is made in compliance Joaquin County Public Health Services. f-fyAp City �� Lot Size/Acreage �y Job Address / PhoneQI It�ANGI� p i.! Address 5 Z O ' Owner's Name , - �j�rc�-'�'ai� �•� Ctsntrar for S s�e� Address i� 4Yler.��n 5� CSGo� Uicense No. -Phone NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION "C1 Out of Service ti1e11 Ll TYPE OF WELtlPUMP. OTHER 5otoring Well Li SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ r ' DISPOSAL FLO.�� PROP• LINE -�1 DISTANCE TO NEi4REST:-SEPTIC TANK-.: y��-SEWER-LINES FOUNDATION", --- AGRICULTURE WELL � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - Clanteca Dia. of Well Excavation y" Dia. of Well Casing n Industrial ❑ Open Bottom Specifications Type of Casing___.—_��A � �,ry t7 Domestic/Private ❑ Gravel Pack I.1 Other 'K Delta❑ Tracy Depth of Grout Seal .s t Type of Grout I'i Public I I Irrigation �..Apprart. Depth I I Eastern Surface Seal Installed by A H.P. State Work Done Repair Work Done 0 Type of Pump ,t Sealing Material f{ Depth N ET AC461m ^'vT � S wow Destruction M Well Diameter --— Filler Material & Depth 150 ain A Depth rmitted if ublie sewer is TYPE AF SEPTIC WORK: NEW INSTALLATION I k REPAIR/ADDITION I i DESTRUCTION I i availabletc systemw thin 200 feet.l p Installation will serve: Residence Commercial Other�—�— Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3.feet: No.L�h partments 0 SEPTIC TANK ❑ Type/Mfg Capaci -- Mef Disposal PKG,TREATMENT PLT ❑ Property � Distance to nearest. y Well Foundation Total length/size LEACHING LINE ❑ No. & Lengt Ines Property Line FILTER BED C] Dis a to nearest: Well_ Foundation �— I 1 Depth -Size Number SEEPAGE PIT Property Lina SUM 0 Distance to nearest: Well Foundation DISPOSAL PONDS 13 i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signatur certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to ecome subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the fotlo "I certify that in th performance of the work for which this permit is issued, I shall employ persons subject to workman's campensa tion laws a•for Pll The applicant II all e i spections. m late drawing on reverse side. �t Title: Ji T " �� Date: Signed St/VV5 TW! - R DEPARTMENT USE ONLY -Date /b tas # Application Accepted by It nal Inspection by Data. Pit or Grout inspection by Additional Comments: Applicant - Return all copies to': San Joaquin County Public Health Services Environmental Health Permit/Se:rvice-s I 445 N San Joaquin, P O Box 2009 Stk K RECEIVED BY DATE FERMIT'NO. lK} FEE AMOUNT DUE AMOUNT REMITTED CASH k INFO + fill 17.2 (REV. I I r SI �9 03_ so r fH 14-16 +