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APPLICATION JOAQUIN COUNTY PUBLIC HEALTH SERVICES I� SAN VIRONMENTAL aEALTH DIVISION 5 N SAN JOAQUIN, PHONE (209)468-1- 3420 STOCKTON, CA 95201 . h 44 p 0 BOX 20099 IT ggPIRES 1`YEAR FROM DATE ISSUED PERM Triplicate) (Complete in i, the Work bed de]as� a��dof sans il. Joaquin County for a permit to construct and/or install plication is hereby e to San woah 3aa Joaquin County Ordinance No. 549 and 1862 and the Rules and Regu hlicetion is made in,camt)li Lot Size/Acreage I �quin County Public Stealth Services. City �� ' C Phone Job Address I Address phone owner Name �-, v_�r. License No. Nell I�. DESTRUCTION C1t °f service Well 1 Com, e,�tif_ Address Monitoring C7 1 Gontraclar NEW WELL 0 �` WELL { `pCAGEMENT i 1 OTHER 0 SYSTEM REPAIR 0 PROP. LINE `TYPE OF WELt1PUMP: TION ❑ DISPOSAL-FLD._ -� .. PUMP iNS7ALLA SEWER LINES �' P.f7l..SlJMPS �- DISTANCE NEAREST: SEPTIC TANK , —� AGC L U E �OI F.OUJ�APJIQ a PROBLEM AREA CONSTRUCTIQN SPECIFIC 4TIONS Dia. of Well Casing yTYPE OF WELL Dia. of Well Excavation Specifications INTENDED USE I ❑ Man - p Open Bottom TVPe of Casing_ Type of Grout n industrial0 Tracy ON Gravel Pack Depth of Grout Seal i I r [1 Domesticl Private .f i l Delta 1'1 Other Surface Seal Lnstatled bS !"I Public lM�ApProx, Depth I i EasternStatWork Done — I I'lrri0at;on H.P. i. 0 Type of Pump -�� Beating Material G Depth 1 Repair Work Done Iz ell Diameter _�-- Filler !Material & Depth tic system permitted if public sewer is y w Well Destruction �pth { -r \available within 200 fest-1 �- SEPTIC WORK: NEW INSTALLATION I REPAIFUADDITION i I QESTRUCTIOIVI I Ova(Nd sap TYPE AFS idence)`' Commercia Installation-will serve: R`es Water table depth Number of living units: �E! Number of b oms � i No. Cmrt+partments T I th of 3 feet: "Cap roc fy � character,of Soil to a If$- TypelMlg Method of Disp3 `_ i, 5EPTSC TANK f l I +h i " ! b Property Line PKG. TREATMENT PLT.❑ Well Fou^dation —— �� Distance to nearest: I I t Totallengthlsizrt f F fLine p9 No. & Length of lines ._.-_. p� Property LEACHING LINEw Well Four' --- FILTER BED Distance to nearest: 4 . . 1 1 Number r Line 00 r I jig`S3epth Property r SEEPAGE PITS �� We1l� Foundation _'-t` k and SUMPS 'LI Distance to ne1rest: _ „. -.9, f f DISPOSAL PONDS i ❑ ' nation and that the wofk will be done in accordance with San Joa4uin County ordinances, state laws, VIII not l ed PP t I hereby certrfy that I have prepay ty rtormence of the work for which this-Farmit is issued, rules and regulations of,�the San Joaquin ifieS the following: "Lrtity that in the Pe i Homeowner or licensed agent's signature S nner n 1O)AC which this permit is issued, l shall employ persons subject to workman's comperica ma subject to workmanls�mpensation laws of California."'Contractor's hiring or�sub-contracting sgna ur F employ any person in such ace sof she xv� r certifies the following:4i1 certify that in the peri e tion taws of California.�� �r t The applicant must i1 far all r ed inspections. omplete d ing on reverse side. pate' # Title: Signed X „ `�,�q f Signed FOR ,TMENT USE ONLY ( �/ Area Date- ii ,� Application Acceptedi iy 0 e Final inspection by � .. P" -or Grout Inspection by > . Additional Comment.:. Joaquin county public Health Services - Return all copies to: San" t Applicantx Env r,onmen al Health Permit/SeryiStkn, CA 95201 445 N San,.-Joaquin, P O Hox 20 , CK DATE PERMIT N0. _ RECEIVED BY ffE� AMOUNT DUE �` . AMOUNT REMITTED CASH INFO . EH 1324 1REV.I 9'9l ,..ql �; s