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Q. <br /> i <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 209 468-3420 <br /> UIN ) <br /> 445 N SAN JlA� , PHONE ( <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> )PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> { (Completer in Triplicate) <br /> Application is hereby made to San Joaquin County for a Permit to construct and/or install the Work herein described. This <br /> application is made in compliance- vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health/Services. <br /> Job Address City �090 r---- Lot Size/Acreage <br /> t r'otlt)taiOrB�laj� GtGq- QJ�`'�' <br /> Dwnar's Name � ' Address T 2 � /o67 Phone 3� a <br /> r <br /> Contractor Hddress �a ,�� License No. <br /> -`� Phone x33/ <br /> PE OF WELL/PUMP: NEW WELL D WELL REPLACEMENV71? DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well {] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL .f OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> C-1 industrial ❑ Open Bottom e 0 Manteda J.,3r Dia. of Well Excavation Dia- of Well Casing ( _ <br /> r,. 1W1, <br /> f I Domestic/Private L-1GravelPack ❑ Tracy Type of Casing_ Specifications <br /> VI Public I-1 Other . (1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ^Approxi Depth ( I Eastern \jSurface Seal Installed by <br /> Repair Work Done U Type of Pump r H.P`� f - % _ State Work Done _ <br /> Well Destruction D Well Diameter k'Sailing Meter i . ; r �t <br /> ,• - <br /> Depth , Filler Material & Depth i3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION I I ft) septic system permitted it public sewer is <br /> ,. tv available within 200 feet) <br /> installation will serve: Residence— Commercial_ Other <br /> ff r � <br /> Number of living units: ___!_ Number of bedrooms <br /> Character of soil to a depth of 3 feat: %Nater table depth <br /> SEPTIC TANK. Type/Mfg .. `r Capacity 2•( 'No.fCornpartments <br /> PKG. TREATMENT PLT. i - j; Method of Disposal <br /> Distance to nearest: Well .Foundation Property Line / <br /> r r <br /> LEACHING LINE No. & Length of lines r Tota jlength/sue <br /> I _.--i+... 4a <br /> FILTER BED ❑ Distance to nearest: iWell • OO J- Foundation Property Line -- <br /> r r <br /> SEEPAGE PITS I Depth -2J �Si:e�z FSG r Number <br /> SUMPS ( Distance to nearest: .Well� �Foundation �� Property Line <br /> AL PONDS ❑ w ; <br /> I hereby certify that I have prepared this application a id`ttfat'the work-will-be done-in accordance with San Joaquin-county ordinances, state laws, and <br /> rt rules and regulations of the San Joaquin County s. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the parformance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting 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 /> rsig: <br /> plicant m all for all requir insectp ' Complete drawing on reverse side. <br /> Title: r9ecJ►y�- _-- Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by 1 ` Date Ares <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> a4 Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> i <br /> FEE AMOUNT DUE f AMOUNT EMITTED CK 11 CEIVED By DATE PERMIT NO. <br /> INFO <br /> . till 1�`2t tREV.1/951 <br /> fH N•2a <br />