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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby compliance <br /> withuSanCJoaquinfor <br /> CountyrOrdinanceconstruct <br /> No. 549and/or <br /> 1862install <br /> and thethe <br /> Rules andherein <br /> Regul.ations of SanThis <br /> appllcatlon is made in comp <br /> Joaquin County Public Health Services. <br /> �+�-700 Sly 4-TV A/ R k� City t 1N € Lot Size Acreage <br /> Job Address <br /> Phone <br /> Owner's Name <br /> If/2A1G Address <br /> .4P�,e�47���- ,amu r• <br /> Contratfor, <br /> 6 Address S License No. 2& _Phone <br /> TYPE OFWELD NEW WELL ❑ WELL REPLACEMENT .❑ DESTRUCTION Cl Out of Service Well Cl <br /> PUMP INSTALLATION C3----' SYSTEM REPAIR C1 <br /> OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> F1 Industrial C3 Open Open Bottom C7 Mana.. ` Dia. of Well Excavation -- <br /> `�f Type of Casing__ Specifications <br /> n Domestic/Private ❑ Gravel Pack ❑Tracy Type of Grout <br /> I'! Public i-1 Other Ll Delta � Depth of Grout Seal <br /> I i Ini anon Approx. Depth I I Eastern Surface Seul Installed by <br /> State Work Done ._ <br /> Repair Work Done LJ Type of Pump H.P. <br /> - 9 <br /> Sealing Material & Depth <br /> Welt Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIRIADDiTION I I DESTRUCTION I I Mo. <br /> s Bti system <br /> y n m permitted if public tower is <br /> availaInstallation will serve: Residence�✓... Commercial_ Ot'her <br /> Number of living units: --. — Number of bedrooms <br /> Character of soil to a depth of 3 feet: S/¢ICJb `" Water table depth ` <br /> qLL Capacity 2-A: No. Compartments V{t\\ <br /> SEPTIC TANK. 0 Type/Mfg <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> i <br /> Distance to nearest: Well,Ar'40 Foundation 3V r Property Line <br /> p r <br /> LEACHING LINE �No. & Length of lines Total lengthlsize , <br /> FILTER BED ❑ Distance to nearest{ Well- a C4 Foundation -50 fOL. Property Line <br /> SEEPAGE PITS I Depth __ O —Size Z Number <br /> SUMPS Ll Distance t nearest: d <br /> ell `����` Foundation f90 ..- Property Line <br /> DISPOSAL PONDS <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 /> rotes 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 shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California'=.Contrectof's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall empl3�-ps r[sons subject to workman's compensa- <br /> tion laws of California.",t - - <br /> The applicant must call for'ail required inspections. Complete drawing on reverse side. <br /> Signed52 <br /> Title: _. ' ate: 7�6—`�3 <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Date- rea / <br /> Application Accepted by <br /> i Date Final Inspection by f� Date Z <br /> Qd <br /> ouion by iOn6� nts: f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> CK <br /> e FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMFT'NO. <br /> 1! f <br /> INF <br /> O/ 1 �0 <br /> 1; EH 13-24 IREY.i i n s) 5 1� I �*:� <br /> EN 11.20 ! Y <br />