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APPLICATION r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 wo .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I-b CS t- LC � (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance Wo. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f� x Job Address 1140 /< Cir; ' Lot Size/Acreage Owner's Name z-,Aak7 . uj00PDVI Address �Q v �a ON tC 'J RAD Phone / `53 C2 At Contractor A. Address License No. Phone TYPE Of WELL/PUMP: W WELL ❑ WELL REPLACEMENT ❑` DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTAL ❑ SYSTEM REPAIR ❑ R ❑ Nonitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FLD. PROP. LINE t - FOUNDATION AG LTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM STRUCTION SPECIFICATIONS f•1 Industrial teca Dia. of Excavation Dia. of Well Casing fa Domestic/ Private ❑ Tracy Type of Casing__ Specifications V] Public n Delta Depth of Grout Seal Type of Grout I I Irrigation I I Eastern Surface Seal Installed by - Repair Work Done U Type of Pump IPP. State WorkTR Oo iii Well Destruction ❑ Well Diameter r e & A th Depth P d`'ile 1,74 t '® TYPE OF SEPTIC WORK: NEW INSTALLATION I I REP}74A DITION i I DE ON IV;-se fi system parniiiled-if public sewer is v1 i i If[ - Installation will serve: Residence Commercial P01 y have ey,0IFF av within 200 feet.) ___-. r( d wftho,# Number of living units: Number of bedrooms t ��rVOW Character of soil to a depth of 3 feet: - 7t/1 sf r �n`��'�e�rater table depth t SEPTIC TANK. ❑ Type/Mfg f Capaci yea"Lll_1_-13ionNo. Compartments I PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size # FILTER BED ❑ Distance to nearest. Wefl Foundation Property Line SEEPAGE PITS 11 Depth Size Number f SUMPS L'I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby ce y that I have spared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and re lations of the an Joaquin County N �. Home owns ar licensed ag is signature certifies.the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any rson in such nor a to become subject'to workman's compensation laws of California."Contractor's hiring or sub-contracting signature j certifies the Rowing: "I ce f the a performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- tion laws of if r The applican i pections. Complete dray ilnq-on reverse side. A wy T Signed X Title: � � .._ ._ Date: FO EPARTMENT USE` ONLY'- 4 r. _�- _t -i Application Accepted by l_ `i!� r m 'Date -..�O t 1 R_ Area L Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE Y INFO AMOUNT DUt? AMOUNT REMITTED CK I ASI4 RECEIVED BY PATE PER^MIT'N0. . £H 13-24 WEV.i i x 5r ��y Qty t 6 4y !I EH 14-2e L -[ Lt� Ll