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APPLICATION <br /> L- <br /> JOAQ N COUNTY PUBLIC HEAL c <br /> RONMENTAL HEALTH DIV SLD 20 <br /> ST <br /> S JOAQUIN, PHONE (20 )�§ <br /> Abp # P O % 2009, OCSTON, <br /> tt PERMIT IRES 1 YEAR FROM DAAA Q# <br /> (Complete in Triplicate)e ,�a <br /> difNY k herein described. Thl <br /> 1 V tt e n <br /> A <br /> ereby made.to San Joaquin County for a permit to construct a i <br /> application Se p�uLllcnHea�lthl3erviceah inn Joaquin County Ordinance No. 5 9 an ' <br /> ts. Joaquin Count � ( �� GL Lot Size/Acreage --- <br /> job Address . Phone <br /> 1 S.t�v` RAS/` Cyjfal/ )ddress <br /> Owner's Name _ - 1_ License NoC Phone �� <br /> �, ,-�,�I4 Address DESTRUCTION ❑ Out Mo Service Well ❑ <br /> Contractor WELL REPLACEMENT Ll Monitoring Well ❑ <br /> NEW WELL ❑ <br /> Vr TYPE OF WELL/PUMP SYSTEM REPAIR L) OTHER ❑ <br /> PUMP INSTALLATION O DISPOSAL FLD. PROP. LINE _- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> � TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED_ Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications— <br /> L) <br /> Gravel Pack ❑ Tracy Depth <br /> of Casing_eel Type of Grout <br /> ` Cl Domestic/Private fl Delta Depth of Grout Seal .�---- <br /> rI Public 17 Other <br /> SuAace Seal Installed by <br /> 1 1 Irrigation _Approx. Depth 1 I Eastern State Work Dona_ �7 <br /> Type of Pump ----L <br /> Repair Work Done L3se A SeDe <br /> sealing Material Depth <br /> V Well Destruction ❑ Well Diameter <br /> Filler Material & Depth <br /> Depth _------ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1( REPAIR/ADDITION I 1 DESTRUCTION I I availablelw thin 200 last.) d public sewer is <br /> low installation will give: Residence Commercial <br /> Other <br /> Number of living units: -J— Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: V Capacity L_ SPS No. Compartments <br /> Is. SEPTIC TANK ❑ Type/Mfg E Method of Disposal <br /> PKG. TREATMENT PLT. ❑ NOT-IN <br /> Distance to nearest: Well <br /> Foundation_a Progeny Line <br /> Ise �t�0 Total length/size <br /> LEACHING LINE No. d Length of lines /�� �Pro ert Lino <br /> FILTERBED <br /> ❑ Distance to nearest: Well Fountlation ...0(�� p y <br /> ` Size Number <br /> SEEPAGE PITS ( I Depth Property Line <br /> SUMPS <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ nances, state laws, and <br /> r, I hereby certify that I have prepared this application and that the work will be done in accordance with San J(ryR�a (C� v <br /> rules and regulations of the San Joaquin County 1 wftk' F E <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the Pei' rn the work or �c 7 S;ab <br /> it o issued, signhallature not <br /> N+ 1 rkman's compenss <br /> employ any person in such manner as to become subject to workman's compensation lawn o1 California." Core c hit�We� b-contractin si nature <br /> certifies the following:"1 cenify that in the performance of the work for which this permit is issued, I shall efpDLoy�pOtsA�IIV I�V�IY 119 <br /> tion Iowa of California." pUE3LIC HEALTH SERVICES <br /> The applicant must call for requ ed inspe jons. Complete drawing on reverse side. ENVIRONMENTAL HEALTH DIV 1 194e z <br /> Data: <br /> Title:am �� ` ✓- <br /> Signed X <br /> FOR DEPARTMENT USE ONLY �1 <br /> Date ��" ! _ 2 ,3 <br /> Area �����i� <br /> Application Accepted by jadid- Ci..eaJ Date 1u 2 <br /> t. Date _ Final Inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: ith <br /> ` Applicant - Return all copies to: San Joaquin blic Hea <br /> Environmental oHealth untY upermit/Servicesvices <br /> 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 <br /> ` � ' FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE P(EERMITE"NNO. <br /> INFO / tJ /y.,/, 1 I E��` 6 0 � f 1 <br /> EN 163e <br />