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APPLICATION • <br />JOAQUINSAN •` <br />ENVIRONMENTAL HEALTH DIVISION <br />P • BOX 2009t ` • : tF 1' <br />t) 468-3447 <br />(Complete in Triplictte) <br />Application to hereby lhade,to San Joaquin County for a permit to construct and/or install the Mork herein described. This <br />application is oolde in compliance with Sen Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San <br />Joaquin County Public Health Services. (� /�, 5D.4(nP�(-• <br />Job Addressor�t ord Lancs aq� g S• r6"Si�1 n City Of- _S+0Ck Vhot Site/Acr age <br />PCA [o'Lrrt� >Mmivt <br />Owner's Name r 1 ,� Address hone <br />Cont(actors(Dech-y"m Address `JE if <br />re CS� iEense No. 5122-69 Phonee----I ^'��'Z <br />mil OF W147PUMP; <br />NEW WELL5Z WELL REPLACEMENT CI DESTRUCTION O Out of Service Well <br />AMOUNT REMITTED <br />CK <br />PUMP INSTALLATION O SYSTEM REPAIR C1 OTHER O Monitoring Well 0 <br />DATE <br />DISTANCE TO NEAREST: SEPTIC TANK �a'� SEWER LINES , DISPOSAL FLD.� PROP. LINE 12L,30 , r <br />l'S <br />FOUNDATION AGRICULTURE WELL OTHER WELL?50 PITS/SUMPS �_ 1 <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '►„f <br />42_1-y <br />fl Industrial <br />O Open bottom O Maniacs Dia. of Well Excavation Dia. of Well Casing <br />U Domestic/ Private <br />""�� <br />Gravel Pack Q Tracy Type of CasingC�tA,tlw�_®., Specifications <br />M Public <br />Cl Other O Delta Depth of Grout Seal e Type of Grout <br />G Irrigation <br />Approx. Depth Wiestern Surfilea Seal Installed by Spo <br />Repair Work Done U <br />Type of Pump -- H.P. State Work one __ <br />e.4 <br />Well Destruction O <br />_, go <br />Well Diameter t wing Material iZ Depth ce <br />-4) <br />on o foci <br />Depth 100' filler Material a Depth <br />^43 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br />(/1 <br />available within 200 feet.) <br />Iniitagation will serve: <br />Residence Commercial `... Other <br />Number of living units: <br />Number of bedrooms <br />Character of soli to a depth of 3 feet: Water table depth <br />SEPTIC TANK <br />O Typo/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />Cl Method of Disposal <br />Distance to nearest: Well Foundation Property Li T <br />LEACHING UNE <br />O No. 6 Length of line$ Total length/site-RECEIVEDi <br />PILTEA M <br />n Distance to nearest: W611 Foundation Property <br />SEEPAGE PITS <br />11 Depth Site Number SAN JOAQUIN <br />SUMPS <br />LI Distance to nearest: Well Foundation PLr� i DIVISIOM <br />DISPOSAL PONDS <br />O <br />I hereby certify that 1 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 porion in such manner as to become subject to workman't compensation laws of California." Contractor's hiring or subcontracting signature <br />certifies the following: " i certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The rrpplic It tell for al r' orad ins p• tions, Co plata drawing orad side. <br />r <br />46 <br />Sig Title. s Date: <br />FOR pEPARTMENT USE ONLY <br />Application Acteptod by Date f gZ. Arse % <br />Pit or Grout Inspection by Date Final Inspection by Data 2t? 9 L <br />r <br />Additional Comments: _ <br />Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br />446 N SAN JOAQUIN, P O 8009, STOCKTON, CA 95201 <br />. Eh 13•t1 tREV. veer <br />EN :1.2a <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK <br />RECEIVED By <br />DATE <br />PERMIT NO. <br />. <br />yl, ��. <br />42_1-y <br />