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*MOAPPLICATION <br /> nJ SAN JOAQUIN COUNTY PUBLIC61= SERVICI�0 <br /> ENVIRONMENTAL HEALTH IS ON 6'g-3 <br /> \i 445 N SAN JOAQUIN, PHONE ( 420 <br /> P O BOX 2009, STOC%TON,} CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS <br /> (Complete in Triplicate) r <br /> Application Is hereby mode to Sm Joaquin County for a permit to construct and/or SndiiaTl'"t his <br /> application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> t. J Services. <br /> Job Address y67� <br /> - — �� pd p1� Cily,6 �o Size/Acreage V� 'nnlzt <br /> Owners Name U�tlie ��R9C'ff Address cZ 93S ;114iC'IZV"S- f'V&'z S_ Phone -Y <br /> I. <br /> C W -1-3"1,o e SP 1dress - i! �J icense No. <br /> Contracwr a � Phone-S <br /> TY OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service W 0 <br /> 60 7d D PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ MonStori ell 0 <br /> NSTANCE T AR ST: SEPTI ANK r S R LINES J DISPOS PROP. !�� Q <br /> O DATION AGRIC ELL J R WELL�_ /SUMPS .� <br /> LINTENDED USE TYPE ELL PROBLEM AREA CONSTRUCTION SPECIFICATION Q <br /> ❑ Industrial 0 Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> LJ'Oomestic/Private 0 Gravel Pack - 0 Tracy Type of Casing Specifications (� <br /> I'I Public 1-1 Other fl Delta De ut Seal Type of Grout \\`p <br /> i I knuation —Approx. De th Surface Seal Installs <br /> Repair Work Don ype of Pump H.P. __ State Work Done_ <br /> estruction O Well Diameter Sealing Material i Depth V <br /> It. DepthFiller Material a Depth - Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 1�` <br /> available within 200 feet.) 111 <br /> Installation wift serve: Residence L Commercial_ OtherIna <br /> Number of living units: 4— Number of bedrooms <br /> Character o1 soil to ■ depth of 3 feet: Water table depth r <br /> SEPTIC TANK 0 Type/Mfg p1f4Z Capacity 1600 No. Compartments t�l <br /> a. PKG. TREATMENT PLT.0 Method ofDi <br /> '�c� �asp,os'al <br /> Distance to nearest: Well Foundation.1_�_ Property Line>_`S,di'S� <br /> LEACHING LINE ❑ No. b Length of lines -3 Total length/size 122 <br /> FILTER BED ❑ Distance to nearest Well . ! Foundation ,L� Property Line 3� r <br /> SEEPAGE PITS I I Depth :?,Zrsize �� Number c7 <br /> r. SUMPS LI Distance to nearest. Well � �� � <br /> ia�� foundation � 'f Property Line aa`7t11i_ 1 <br /> DISPOSAL PONDS ❑ <br /> 1 hereby 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 /> rules and regulations of the San Joaquin County <br /> Home owner or licensed a ent's signature certifies the following: y performance of the work for which this permit is issued. I shall nor <br /> g g g: "1 coni( that in the <br /> employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <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 laws of California." <br /> The appbca ����}}''st call for all requr Inspections. Complete drawing on reverse side. <br /> Signed� � _ r Title: ) r/(/_L�/}/ Date: <br /> FOR DEPARTMENT USE ONLY <br /> r � Q_ <br /> E� <br /> Application Accepted by Date ` ^v:--- =� raa <br /> , <br /> -P.t r Grout Inspection by r �Data Final Inspection by OR 2.7 <br /> r <br /> AAMnel Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> r \ia i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> 'it'�1r,�•+ INFO AMOUNT DmmVE,, AMOUNT R�EM�I,T\TEDjl;�13ASH ///�flECEI(V�/EDy/J'BV� / �//� DAT/E �] �/fP/�ERMIT N0. <br /> EM 1]2e(REV.tie sl / tl✓ ... // . f/U / 5 / 7� / /2/ 143 !/.�—/�,? <br /> EM Ia]a <br />