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w• 1 <br /> �•-� APPLIC I, rTnP4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PER911 MIRES, YEAR R DA U� <br /> (Complete In Triplicate) <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 wade 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 /> Job Address 2529 Waterloo Rd. city Stockton Lot. Size/Acreage 14,400 sq ft <br /> 'Loll <br /> Owners Namei argarate Boti_12er Address 1856 W Monterey, Stockton, CA Phone 209-948-2669 <br /> 3663 Omec Circle <br /> COntrZiCtar B&iF_.Drilling Address Rancho Cordova, CA 9576&fise No 519428 phone 916-631-9546 <br /> TYPE OF WELL/PUMP NEW WELL EN WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well [i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTTER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7- <br /> 2" <br /> {i Industnai ❑ Open Bottom ❑ Manteca Ora of Well Excavation 81, Dia of Well Casting <br /> f t Domestic/Private CH Gravel Pack C3 Tracy Type of Caspng- PVC Specifications SCh. 40 <br /> i t Public I"l Other n Delta Depth of Grout Seal 681 Type of Grout Cement _ C <br /> I i Irritation " y Tritllme ' ~ <br /> �Approx Depth [ f Eastern Surface Soul installed b <br /> Repair Work Done U Type of Pump NA H P State Work Dane , <br /> Watt Destruction ❑ Wall Diameter 21' Scaling Material i Beeth Cement to Bentonite, seal - 68" <br /> Depth 90" filler Material & Depth Silica sand filter ack --70' <br /> TYPE OF SEPTIC WORK NEW INSTALLATION! I 1 REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permit ublic sewer is <br /> evadable within et l <br /> Installation will servo Residence_ Commercial- Other <br /> Number o units Number of bedrooms <br /> Character of soli to th of 3 feet Water table depth <br /> SEPTIC TANK ❑ Ty <br /> Capacity No Camjsartrreents <br /> PKG TREATMENT FLT ❑ Method of Disposal <br /> Distance to nearest Foundation Property Line <br /> LEACHING LINE ❑ No b 8th of lines Total length/size <br /> FILTER BED ❑ tans to nearest Weil Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest Well Foundation Property Lina _ <br /> OISPO; 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 agent's signature certifies the following I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman s compensation laws of California Contractors hiring or sub-contracting signature <br /> certifies the following 1 Certify that inIhe performance of the work for which this permit in issued, t shall employ persons subject to workman s compensa <br /> tion Iowa of California "' <br /> The applicapt must call for all reqifffwInspections Complete drawingreverse side 'r _ <br /> Signed X Title • Date <br /> I W1 <br /> �E ARTRR USE ONLY <br /> Application Accepted by r r v Date Area <br /> Pit o►Grout Inspection by Data Final Inspection by Date <br /> Additional Comments <br /> . Applicant - Return all copies to San Joaquin County Public Health Services <br /> �O / <br /> Environmental Health Permit/services J` f[ <br /> 445 N San Joaquin, PO Box 2009, Stkn, CA 9S201 <br /> FEE AMOUNT DUE AMOUNT RERAITTEO CK RECEIVED 8Y S <br /> INFO (� CASH DATE PFtRM1T NO <br />