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3 ,` - APPLICATION <br /> .. <br /> . SAN JOAQUIN COUNTY PUBLIC 13 AL CSS ? <br /> (� '� ENVIRONMENTAL HEALTH DYv Y <br /> '77' 445 N SAN JOAQUIN, PHONE (209 �} i2fJ <br /> ypglv"Mi P O BOX 2009, STOCKTON, CA GY" <br /> S's\a (Complete in Triplicat 'INV# <br /> Sa <br /> Application 1■ hereby made,to e Joaquin County for a permit to construct end f�■ <br /> applicationis lade 1n compliance with $an Joaquin County Ordinance Hn. 549 end 1962 and the Rules and Regulations or Saul <br /> Joaquin County Public Health Services. <br /> Job Address City Irary Lot Size/Acreage <br /> Owner's Nome L e e Sustaire Address$$,Q8 S e h l l l}e-, T r a r v Phone 532-7999 <br /> Contractor Hennings BT'OS. Address 3525 Pelandale. MQjd License No.-Z9-D8_L3---Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT)rX DESTRUCTION P1 Out or service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK - 100 I SEWER LINES DISPOSAL FLD. 10{l t+PROP. LINE lil—' <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL_ 50! _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� <br /> n Industrial ❑ Open Bottom Ci Mameca Dia. of Well Excavation_ Dy, of Woo Caving <br /> OD Oomealic/Private Q Gravel Pack CXTracy Type of Casing_— EVC Specilkalions <br /> 11 Public l-1 Other r-1 Delia Depth of Grout Seat ___ 10 0 1 Typs of Grow <br /> I i Irrivadon —Approx. Depth I I Eastern Surfeoe Seal Installed by dirflier <br /> Repair Work Done U Type of Pump H.P. tate Work Dorm, <br /> Well Dattuctlon 11 Well al <br /> Diameter ? seitts Material i Depth Bentonite <br /> Depth Filler Material b Depth Bentonite <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIWADOtnON i I DESTRUCTION I I INo seplic systtmr permitted it public g war is <br /> available within 100 fest.l <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units Number of bedrooms <br /> Character of end to a depth of 3 Nee: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PYG, TREATMENT PLT.Cl Method of Disposal <br /> Distance to neaast; Well Foundalion_ Property Line <br /> LEACHING LINE 0 No. 6 Length of lines Total length/rise <br /> FILTER BED ❑ Distance to nearest: Well Founcation _ Property Lith <br /> SEEPAGE PITS i I Depth Sive Number <br /> SUMPS LI pittance to nasrset.. Wall Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby Certify that a have prepared this application and that the work will be done in accordance with San Jt►tquln county ordinances,stale laws, and r <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agar's slgnolwe certifies the 10110wing: "I certify that in the performance of the work for which this permit is issued,I @hall not <br /> 0"WiDy any person in such manner as to become subject to workman's Compensation laves of California."Cantracmes hiring or sub-contrecling Signature <br /> earttfies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion Lowe of California.'* <br /> The applicant must cap for off mqulrod inspections. Complete dr■wmg on verse ei <br /> Signed Tills: <br /> Data: 8-30-9 <br /> FOR DEPA ENT USE ONLY <br /> Application Accepted by Dau <br /> Ara <br /> Ph or Grove Intpeetkut byData _ Final Inspection by ilft Daly C]'ia4s Cat, <br /> Additional Comments: <br /> Applicant - Retu all 11piea ta: San Joaquin County Public Health Services r �rw1 <br /> . � ttoviroomental Health Perini t/ServLaos <br /> LT�f 445 N San Joaquie, p 0 Box 2009, Stkn, CA 952010= <br /> ,� a E AMOUNT DUE AMOUNT REMITTED <br /> s9 INFO RECEIVED by GATE PERMIT NO. ^ff7q <br /> . lift ti24INLV.1JAaY P— T / <br /> .9 - 00 <br />