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APPLICATION <br /> SERVICES „ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEt <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1445 N SAN -JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95207. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> Tri licate) Thi. <br /> r InBijil. <br /> Application is hereby made to San Joaquin CIth San ounty fora pIIiFmit Ordino constru51+9aand o1862 and the Rules and vork eRegulations doT Bans <br /> application is made. in compliance , <br /> Joaquin County Public Health services. Lot Size/Acreage 9/ 'X Z , <br /> 2,-7;7, J City <br /> Job Address 1 S_ <br /> it 1 , f r Phone <br /> Address / <br /> Owner's Name I# �[ <br /> �Q, License.No. Z- R✓� Phone <br /> Contractor( `� Address <br /> j WELL REPLAGEMEN7 C7 DESTRUCTION Cl put of Service We11 ❑ <br /> TYPE OF WELL/PUMP: NEW WELL OTHER ❑ Monitoring Well C7 <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATI/O/N�i� DISPO�AALD�L.L�C��-- PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TA' SEWER LINES -------�4�yR WELL_�. <br /> FOUNDATION ��-- AGRICULTURE WELL <br /> Tf}iiEE PITSISUMPS <br /> t/ <br /> INTENDED USE TYPE OF;WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS© Dia. of Well Casing <br /> ❑ Open Bottom Manteca Dia. of Well Excavation <br /> nindustrial Type of Casing___ <br /> Specifications <br /> Gravel Pack Tracy � Type of G III1 <br /> Domestic/Private l pelta Depth of Grout Seal , <br /> Irl Public 1-1 Other <br /> 11 Irrigation Approx. Depth 4 I Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done L7 Type of Pump ---�-- Material & Depth <br /> Sealing �v <br /> Well Destruction ❑ Welt Diameter --- Filler Material & Depth J <br /> 1 Depth J <br /> available within 200 feet.I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I i DESTRUCTION I I (No septic system Permitted if public sewer +s <br /> ' — f <br /> installation will serve: Residence Commercial Other <br /> , <br /> Number of living units: _ Number of bedrooms -- Water table depth <br /> Character of soil to a depth of 3 feet: Capacity�_—�—--- No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> ;PKG. TREATMENT PLT Cf, ,, * t <br /> f b ;€ : � Property tine S <br /> k Foundauon ' <br /> y + r wr` 'r .Distance to nearest. <br /> -F <br /> Total length/size' <br /> LEACHING LINE L"1 No. & �engtFi o! lines Foundation Property Line <br /> FILTER BED C) Distance to nearest: Well <br /> p Number <br /> SEEPAGE PITS I I Depth{St_e Foundation Property Line <br /> SUMPS L1 Distance to nearest: Well <br /> I DISPOSAL PONDS Cl If, <br /> I hareby 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 /> j rules and regulations of the San Joaquin County allowing: work for <br /> f l not <br /> Home owner oli enrsedcatgenI signature <br /> to be of Erna s.the I to workmen`s compensation l 11 certify that in the awsofperformance of <br /> Contractor'swhich <br /> rhiring oP sub-contracting ermit is signlature <br /> employ any personmanner <br /> certifies the following: -I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to"workman's compensa <br /> tion taws of Call ornia." <br /> I The appli ust call for all req ' inspections. Com tet&"drawing on er e. l <br /> Title: <br /> Date: •C.� <br /> Signed X <br /> i DEPART E USE ONLY <br /> Date y Area - — <br /> Application Accepted by Z� �}Z <br /> Pit or Grout Inspection by <br /> Date <br /> DateFinal Inspection by <br /> Additional Comments: ! F 0'7 �,e�� ldf f/OjF'{Jv- <br /> an Joaquin <br /> Applicant Return all copies to: EnvironmentaloHealthunty uPermit/Servicesblic ealth vices �5� P , <br /> f[ 445 N San Joaquin, P o Box 2009, Stkn, CA 95201 <br /> I j CK RECEIVED By DATE PERMIT' <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO ,� [�3 <br /> r' [��r O f� <br /> . EM 17.24 IS EV.r i h 51 tN �i n,� �-/ 32 <br /> EM 5426 ._:._ .. <br />