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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 made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is Slade in corttpliance 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 City Lot Size/Acreage Aw-�P.­_� <br /> e <br /> Owner's Name etil(a .�if-C•,if3& Address Phone � } <br /> Contractor + Address_LN Y_ 'L - 16E& License No. � '-1 �Phone -M 63 <br /> TYPE OF WELL/PUMP: 11 -NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION b Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL- PROBLEM A',A CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom 0 . ❑ Ma'rteca � Dia. of Well Excavation Dia. of Well Casing j <br /> f Domestic/Private ❑ Gravel Pack ❑ Tracy i%ype of Casing_ Specifications <br /> I"! Public Cl Other fl Delta' jjspth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Dep h 11 E tiefn SJrfaee Seal Installed by <br /> Repair Work Done LJ Type of Pump "y " LLE-T State Work Done <br /> lea Naterial i Depth <br /> Well Destruction ❑ Well Diameter + �, <br /> Depth GrS. Fille �Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDIYION I I DESTRUCTION € I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial <br /> Number of livings nits: Number of bedroom _ -_....-._. ' lI <br /> Character of soil to a depth of 3 feet: Water table depth <br /> v, < 6c])n No. <br /> SEPTIC TANK. 0- Type/Mfg � Capacity_'i# Compartments <br /> PKG. TREATMENT PLT.0 �' �— Method of Disposal <br /> Distance to nearest: WeIL ~�.Foundation Property Line Igo <br /> LEACHING LINE 0, No. & Length of lines P r ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Welt ' Foundation �r�` Property Line <br /> } <br /> SEEPAGE PITS 4 Depth �J' Size �-- !� Number 3 __ <br /> SUMPS LI Distance to nearest: Well Foundation .+ Property Line 0 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance Iih tan 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; "1 certify that in the performance of the,'ork for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of Calif ornia�>�'Obntractof'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 aM1 ploy persons subject to workman's compensa- <br /> tion laws of California." i <br /> The applicant must c I or all require In c' ns. Complete drawing on reverse side. <br /> Signed X, Jt"►i Title: Date: to <br /> DEPA1i-TMENT-USE- _ <br /> �' tel] 2 Z 1 <br /> Application Accepted by Date Area <br /> CPJor Grout Inspection by a-D to Fi Inspection by Dat �' J <br /> Additional Comments: <br /> I' <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environinental Heath Permit/Services <br /> i 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 l <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. I <br /> INFO <br /> r t�EH 11.26 <br /> tl <br />