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• APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 43A ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 51351 nTrdal-g City Lind— <br /> Rd Lot Size/Acreage <br /> Owner'sNamaKi_]hiir 1{x'en7 Address 5353 N_ Arc]Qrdale Rd-- Phone <br /> Contractopurviance Drill— A na, POBox 64,Linden License No.377923 Phone;887-355TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTxf DESTRUCTION Out of Se Well ❑ <br /> PUMP INSTALLATION k SYSTEM REPAIR O OTHER O Monitori4L ,,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation If/Dia. of Well CasingDomestic/Private O Gravel Pack O Tracy Type of Casing _ StP Specifications-7 RI'l Public fie Other y5t7 in Delta Depth of Grout Seal TIrrigation ype of Grout I <br /> X $$(Wrox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U' Type oG-Pump er_ H.p.25 State Work Dons <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth-_ Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg — Ater table depth <br /> 771 Compartments <br /> PKG. TREATMENT PLT.❑ r 4althod of Disposal <br /> Distance to nearest: Well �! F nda 'on, prty Line <br /> Paint A I FIIIUdkk <br /> LEACHING LINE Cl No. & Length of lines � T }�Gid�' r <br /> e ,� y <br /> FILTER BED O Distance to nearest: W�eell � <br /> �g}� <br /> 6�IG v ly Line <br /> ne <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS O Property Line <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 laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> y p p y Persons subject to workman's compensa- <br /> tion <br /> the following: "I certify that in the performance of the work for which this permit is issued, I shall em to <br /> tion la lifornia." <br /> The Opplicant nrjj1ist or I r ired inspections. Complete drawing on reverse side. <br /> Signe <br /> Title: —t^nrn 4r��rofar� Date: _ 4/21 /92 <br /> F DEPARTMENT USE ONLY i <br /> ` F <br /> Application Accepted by r7, l�� s y. <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspectio by <br /> �( Date <br /> Additional Comment:: ( /0 ' r ;zy0 y6 <br /> Applicant Return all copies to: San Joaquin County Public Hea th Services 7te it'f 4-16 Q� <br /> /y, h En ronmental Health Permit/Services <br /> 1 I' 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> IN CASH RECEIVED BYEDATE <br /> . EM 17.26 IREV.r i x s1 r,-G <br /> "� 1`y� <br />