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3 _ _ <br /> APPLICATION �+e Q <br /> al:0o- 1:36 46•-_- SR # FJ <br /> 3f� 9AN JOAQUIN COUNTY PUBLIC TMSE ICES �D <br /> 313e14jfr _ /a p 30 ENVIRONMENTAL HEALTH DI ONii►► <br /> 445NSAN J2009220 <br /> , STOCKTON( C )1A1`'�}}4 <br /> P0 BOX <br /> PERMIT EXPIRES 1 YEAR FROM D itl`[t690� <br /> (Complete in Triplicat ` \ <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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.. ` <br /> 2323 "/ f/G�/fC� /lea / ��/�Fi✓S •cn 1 «a ag�7S S eCF Z <br /> Job Address Lot Size/Acre <br /> Owner's Namri-O/J / /)7' <RN TOS 01-IfAddress t!��D ��S y �f!9 HCl ir3`r, cEi°- Phone - U <br /> v <br /> F/Ic'S N O C.4 -13 7Z 1— yf'IO-.S"7 7 <br /> ConvactorZLJ( El7JPhone A0'1-934-133 S7 " <br /> TYPE OF WELL/PUMP: NEW WELL ZI­ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ f <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. `¢P��RR+OP. LINE <br /> FOUNDATION Z.o�6� AGRICULTURE WELL OTHER WrELL3yb6'PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PF19BLEM AREA CONSTRUCTION SPECIFICATIONS = <br /> D Industrial ,❑,�,�OOpen Bottom Manteca Dia. of Well Excavation Dia. of Well Casing /D <br /> LI D astic/Private s�roravel Pack D Tracy Type of Casing_ .57��� Specifications <br /> I ublic (.1 Other D Delta Depth of Grout Seal /00 r Type of Grout 5,4.vd <br /> I I Irrigation _Approx. Depth 1 I Eastern Surface Sedl Installed by ZviN .tNCIl� S7ca'� �-irC <br /> Repair Work Done L3 Type of Pump H.P. State Work Done <br /> Wall Destruction ❑ Well Diameter Sealing Material i Depth (�1 <br /> Depth Filler Material i Depth IWC <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will carve: Residence_ Commercial _ Other t� <br /> Number of living units: _ Number of bedrooms CV <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: WellJC5)_ Foundation 6'Sr 7c^ Pro PA <br /> �a <br /> LEACHING LINE D No. 8 Length or lines Total len 1"' <br /> FILTER BED D Distance to nearest: Well Foundation PMAR, Lin* <br /> SEEPAGE PITSMly 1 1 Depth Size N��r VIN CMIT <br /> SUMPS LI Distance to nearest: Well Foundation FNVjR IcA��� ' Si=R�IOE$ <br /> DISPOSAL PONDS ❑ 9p IV�ISION <br /> I 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 agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not <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 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 ust call for all uiryd inspections. Complete drawing on//reverse <br /> side. <br /> Signed X � GC! d� Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by `� Date Area � ./ <br /> Pit or Grout Inspection by Date Final Inspection by Date D 71_ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Pu Sc Health Services W *d 9 r.1Cvz{f <br /> Health Perm.t/Seryl ces <br /> 445Environmental ( / <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE <br /> INFO AMOUNT DUE A OUNT REMITTED CASH RECEIVED BY DATE PEflMIT'NO. <br /> • EN 17-24 MVV.r r x m <br /> EH 1470 <br />