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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC H$ALTH S a1 R <br /> ENVIRONMENTAL HRALTH DIVISI <br /> 445 N SAN JOAQUIN, PHONE (209)46 <br /> P O BOX 2009, STOCKTON, CA 95 <br /> p <br /> (Complete in Triplicate) INV# Sa <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or is c <br /> application to stile in ecsVllsace ,with San Joaquin County Ordlnaace No. 5k9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> .lop Address �gSO lV �L tZ � Clty fh Cd Lot Size/Acreoge <br /> Ownw's Name WF'Ulf We— Address --+ e phone <br /> Contractor _I 1 PSI �II�Ge�'e Address_��� f "V &Vp-L,cense No.2 7�7l& Phone8_7 <br /> TYPE OF WELL/PUMP- NEW WELL rJ WELL REPLACEMENT fl DESTRUCTION Cl Out of Service all <br /> PUMP INSTALLATION O SYSTEM REPAIR n OTHER ❑ Nooitcring Nell O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> 0 industrial O Open Bottom O Manleea Ors. of Wa*Excavation "cuing <br /> [:I Domestic/Private O Gravel Pack7 0 Tracy Type of Casing_ �fioAs <br /> 11 Public rl 011ier fl Doha Depth of Grout Sall <br /> I I IftwTion —Approx. Depth I I Eastern Surface Seal installed by'-"TI fJD>T <br /> Repair Work Dons L7 Type of Pump H.P. Stale pQ�QA�tn�,,, <br /> Wall Destruction O wall Diameter 9ealiog kateris.1 i Depth l�Jv�VyIn y <br /> Depth filler Material i Depth call <br /> ON <br /> >� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/A61—h N DESTRUCTION I I (No septic system permitted it public sewer is <br /> wsiteble within 200 INI.1 <br /> Installation will save: Residence Commercial_„ Other <br /> Number of bvog units: I Number of podroorns__3 <br /> Character of and to s depth of 3 fast: _ water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compertments <br /> PKG. TREATMENT PLT.Cl Method of Oiposel <br /> Distencs to nearest: Wall Foundation Property Linty <br /> 1 t 1 <br /> LEACHING LINE Cl No. i Length of linea Net fatal /size Q <br /> FILTER BED CI Distance to newest. Wert Founoarton Property Lina \ <br /> SEEPAGE PITS I I Depth Si:e Number <br /> SUMPS LI Distance to nearest; Weft Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> hereby certify that i have prepared this application and that the work will be dons in accordance with San.Joaquin county ordinances, gists laws, and <br /> rules and regulations of the Son ioaquin Cowty <br /> Homs owner or licensed penia iignaturs osrtifies the following: '•1 Certify that in the psrlormence of the work for which this permit is imed, I shall not <br /> SMp'o1r Illy Person in Such msmrer as to become Subject to workman's compensation lawn of California.-Contractors hiring or sub.eonttacting signature <br /> certifies the fokwinO: "I certify Mat in the pWontunce of the work fon which this permit is issued,I ShMI employ persona subject to worktnsn's cornpensa- <br /> Non laws tN California.- <br /> The eppGcsnt must call for all required in ions. Complete drawing on reverse side. � C <br /> Signed ll l L Title: 3y <br /> - -1' 7 y <br /> Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accented by <br /> Pit or Grout Inspection by Data Fid InspectionO Q <br /> AddltbrtN Comnanta: <br /> APP11cant - Return all copies to: Bae Joaquin County public Health ServicesEnv --� <br /> s fj 445 If Ban Jo Health Permit/Services <br /> Stir <br /> 446 If esa Joaquin, P O Box 2009 Btkn, CA 95 <br /> tI/�7�f FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE No <br /> fill I4.al t �J�! <br />