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PLICATION FOR PERMI SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES "• ' =='4.w j ENVIRONMENTAL HEALTH DIVISION '' s:,A,,•� 1601 E. HAZELTON AVE. , PHONE (209)468-3420_- P 0 BOX 2009, STOCKTON, CA� 95201 . r. i RES 1 YEAR FR M DATE ED - - I (Complete in Triplicale) work in d Application is hereby made toS huiSnaACJ quinocounty Ordirmit nance No. 549structga dad/o1662gand the tall eRules andeRegulationedof Sans application is tai in Joaquin County Public Health Services. oC, Ilg� City M i Lot Size/Acreage I Job Address M ,� Phone[ `- Owner's Name /4/0RMR/1 fs AV� Address SI 45 � aJIL(-iNd ,'-/ C_s S'SY9�9_P one}(Oj� r �LlESr Address _Iz 3 3 F/TktG-'v (4-) ST License No. i Contractor DESTRUCTION ❑ Out of Service well 0 TYPE Ot WELL/PUMP: WELL REPLACEMEN ❑ NEW WELL ❑ 0. Monitoring Monitoring Wel]. ❑ SYSTEM REPAIR 3 OTHER 0 SO/_ ,�pKi�lrfs PUMP INSTALLATION pISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ^`—� PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l 0 Industrial ❑ Open Bottom ❑ Mane Dia. of Well Excavation r Rau Dia. of Well Casing U1i4 Specifications �i Domesticl Private El Gravel Pack ❑ Tracy Type of Casing I A Type of Grout I 1 Public fid Other i8DjC1A1tr� Cl Delta Depth of Grout Seal .� lvJfXT N T �0/Approx. Depth I I Eastern Surface Seal Installedl by Be7�rz/!s' ��"��-� I I irrigation TKEi►.r�� r ivc H P f1. State Work Done Repair Work Done L3 Type of Pump ^- 7bT��Di~f'TF1 Tc�C-�fO Sealing Material i Depth kl A/ !�T G 'vtyT'Well Destruction ❑ Wall Diameter —^- Filler Material & Depth 1� f Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I lNo availabptiw thin system f milled if public sewer is Installation will serve: Residence— ComrneTdal— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK C3 Type lMfg Capacityh No. Compartments PKC. TREATMENT PLT,L7 Method of Disposal Distance to nearest: Well Foundation if LProperty Line ' LEACHING LINE 0 No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I� l SEEPAGE PITS I [ Depth Size I Number SUMPS LI Distance to nearest: Well Foundation i. Property tine i DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accaidance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County rtify that in the performance rmCaFfornnce rn ia." Contractor's hiring or subcontracting signature the work for whish this permit is issued, l shall not Home owner or licensed agent's signature certifies the following: "I ca employ any person in such manner as to become subject to workman's compensation laws 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- tion laws of California." The applicant m st tail for all required inspections. Complete drawing on reverse side. r Title: SSM/oR, &-e-D Co Onll Date: Signed It y�tlO Nv/A4�vAl ewr.4 Cr r-{ 0 DEPARTMENT USE ONLY Application ACCaptad by Date �s Pit or Grout Inspection by Date ° �G QL Final Inspection by Date �Z Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health ©o tyr Services, Eavironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton. CA 95201 FEERECEIVED By DATE PERMIT"NO, AMOUNT DUE AMOUNT REMITTED CACK SH INFO . em 3521(HEY.11451 !�� O I �Iv )1 09 r EFF:1.26