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APPLICATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (2U9)46S--3420 <br />P 0 BOX 2009, STOCKTON, CA 55201 <br />FROM 7 f i 1 T. <br />(Complete in Triplicate) <br />lication la hereby Mae to Joaquin Cotmty for s permit to construct and/or inetsll the work herein described. This <br />application is made in ec�,rlianre with Sa.n Joaquin County Ordinance No. rL9 and 1$62 and tier Rules and Aegs,:l.atiora o San <br />Jeaguio County iPublic Health Services, <br />lot size/Acre-g"! <br />airy <br />Jot Address <br />Phone <br />Owner i Name � z S Adtiresa � �r� <br />i�t3t} PennefdJ " <br />Can#rat#rte Address License No __ <br />TYPE OF wELLlPUIVIP: NEW WILL Q WELL REPLACEIv1EfvT L1 DESTRUCTION th+t No niWrtrsg Well <br />PUMP INSTALLATION 0 SYSTEM REPAIR D OTHFfl C; <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br />_ DISPOSAL FLD. PAOP. LINE <br />FOUNDAI`iON _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPIC PRi38LEIIiI AREA CONSTRUCTION SPECIFICATIONS YY Dia of Won Casing <br />1-i lndustrsai Cl Open Bottom C3 Mant�ca Dia-�O V+11rII-Excavation._... Specifications <br />Dorn"llic{Private Ci Gravel Pack 0 Tracy Type of Casing_ _ <br />1"l other f tl Delta Depth of Gfow Seal 1Yiw'oI Gran# <br />I`I Ptsbiic .. ' <br />! i lrri�at syti __ AWOX. Depth I I Eastern Suttace Soni Installed by <br />Repair Work Done i3 Type of Pur tp H,P. State work Done <br />Sealiag Material i Depth <br />Wall Destruction i� well Diamaier Filler Nate °ai Depth '� , <br />Depth <br />TYPE b ------------ <br />f SEPTIC WORK: NEW IN TA L.ATION ' i REPAIAIADDIT}ON I ' DESTRUCTION I i 4No septic. system permitted if public saver lac <br />aysilabts within 200 feet.I <br />installation vii! serve : Rosi once V CommerctaiLL__ flier _ �r <br />Number of Iiyinq units:._:.. Number of bedrooms <br />Chatscter of sod toe sh of 3 fast. . ' y Watd table depth _ <br />SEPTIC TANK TypelMfg + city No. CGIn I'll rents <br />PKG. TREATMENT PLT_ C3 `""""°"""" rsBf of Disposal <br />vaAarice to nearas't: Weil foundata�t�ri' � Property Lute <br />LEACHING LINE Nm $ Length of tines ` Total langthls4e <br />IV *FILTER SEI} n Disianc to nearest: Wali i ' /Foundation _._�h t" Prop 'ty iirur 1e r <br />SEEPAGE PITS I I Depth � _Sue ✓ 2"-A io Nunsber <br />�ye JO' Pro Lirtet �i� ..- <br />SUMPS ✓'" „Distance to nearest welt "✓1! _ , FaunGat,on ps�Y <br />DISPOSAL PONDS CJ <br />I hereby certify that I have prepared thi$ applicatson ands at the work will be done in accordance. with San Joaquin county Ort)inances, stats laws, and <br />rules and regusatitans of Itis San Joaquin County �,_ <br />dome Owner or licensed agt±tnt's signature certifies the following: "i certify that in the perforrnence of the work for which the permit is isxueci. I shall not <br />employ any person in such rmnnar as to brcornEi subject to Workman's compensation law$ 0j'California ', Ccojtrsctor's hiring or sub -contracting $"lure <br />certifies the foiloarir : "I eartify that in the performance of the work for which thispermit is issued,'I shell employ *sons subject to workman's componsa• <br />tion low* of California." --- Ii """"" '° `�•.. <br />The applicant must all r trod i a, Compl$te'dtawing on reverse tribe. <br />. <br />�. <br />Signal X.,.__ _ _. <br />Tina. Mata= <br />: <br />FOUR DEPARTMENT USE ONLY <br />'"` raa �- <br />Application Accepted by C���%. � �.���Jb�ts+I�3 _ Data A <br />Data <br />Pit <br />Pit or Grout Impaction by liars Final Inspection by <br />i Additional Comrrwnts: <br />I r <br />AP i,�nrit`- Reiur i`ali,copiq-s <br />Y -Si i ioaqui.sz'Co"ty 'Publiir Health Serirfceh <br />t <br />Ruvirortmontal stealth PermitJServicee <br />t <br />44E5 N Sari 3oaquin„ P 0 Box 2009, Stkn, CA. <br />85201 <br />i <br />.. ..' <br />r, ..` <br />FEE <br />AbiOtJNT <br />Dt)E <br />RkeOUNT NEfdITlED <br />CK RECEIVED BY <br />CA5N <br />DRTf - ` <br />VERkA1Y Nfl. <br />INFO <br />Ext!-YtsACV, ,,AS?I <br />. �'`j' <br />Qf+ 14.76 i <br />t <br />t.�7 <br />