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N PLICATION <br /> /AQUIN COUNTY PUBLIC HEALTH �j <br /> ENVIRONMENTAL HEALTH DIVISI N "r <br /> _,� 45 N SAN JOAQUIN, PHONE (209)4" <br /> Gpv `S�'�' 4 'i P 0 BOX 2009, STOCgTON, CA5 # �S <br /> Nil <br /> PERMIT T EgPIRES 1 YEAR FROM DAT��I ga <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/ install the wor scribed. <br /> application is made in compliance with Ban Joaquin county Ordinance No. 549~�and 118�862 and the Rules and of San <br /> Joaquin County Public Health Services. <br /> ��7 /" <br />` 3 <br /> Job Address <br /> City Lot Size/Acreage <br /> - - <br /> r tf <br /> di <br /> owner's Name <br /> Adess' y'� Phone r <br /> 1 Of <br /> Cpniraclor! t'ldress License No. Phone <br /> TYPE OF WELLIPUMP: NEW W L ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well L1 <br /> PUMP INSTALLATION 13S TEM REPAIR ❑ OTHER ❑ Monitoring 'WellC7 <br /> DISTANCE TO NEAREST: SEPTIC TANK S ER LI DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A RICU URE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Man c Dia. of Well Excavation ®�f'"�ell Casing <br /> F] Domestic/Private 0 Gravel Pack CO3T cy Type of Casing �'pe�-...cations <br /> 1'1 Public 1:1 Other Delta Depth of Grout Sea{ rout <br /> I I Irrigation T Appro>E, Depth I Eastern Surface Seal Installed by FIR 0 5 1994 <br /> t Repair Work Done U Type of Pump „° P. State 7P1 V6A <br /> r riling <br /> Well Destruction ❑ Well Diameter' Materiel i Depth <br /> tiPt1V V <br /> 5 <br /> Depth PUMLIt- <br /> Filler !Material i Depth 19>� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1K REPAIR/ADDITION l I DESTRUCTION I I (No`septic system permitjed it public sewer is <br /> r available within 200 feet.) <br /> I Installation will serve: Residence Commercial ther <br /> Number of living units: Number of bedroo <br /> FCharacter of soil to a depth of 3 feet: ; Wet tab) depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 1 No. C `m0?rtments <br /> r <br /> PKG. TREATMENT FLT. ❑ Method of Di os <br /> �r Distance to nearest: Well Foundation Noperty Line <br /> �� <br /> LEACHING LINE ❑ No. & Length of lines Total lengt i'l ' <br /> Awl 15 <br /> FILTER BED Cl Distance to nearest: Well Foundation P7iil <br /> ; <br /> SEEPAGE PITS 11 Depth Size N er <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I !hive prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ander <br /> rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies the_fRtIowing: "I certiiy..that in the performance of the work-for which this-permit is'issued, I shall not <br /> I employ any person in such,manneras 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 /> The applicant st call for • aired inspo, ions, Complete drawing on reverse side. <br /> F+ r <br /> Signed ' Title: _„ ��J V” ► _ Date: <br /> FOR,;PEPARTMENT USE ONLY <br /> Application Accepted by Date res <br /> Y r <br /> P' Grout Inspection by ate �7 :Final Inspection by Date <br /> �Z 3t� • r <br /> A diilSnai Comments: , <br /> L Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permi- Services <br /> 445 N San Joaquin, P O 13vx 009, Stkn, CA 95201 <br /> t ; FEE AMOPU�T DUE AMOU T,REMITTEO K RECEIVED 9Y DATE PERMIT'NO. <br /> INFO <br /> r <br /> . EH 11-24(REV iiKsi f �' �i-� �/ / 3 / .LIf'!/S > `' K 5�--' //f✓/if///� <br />