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ri s APPLICA.TIAN. kOR PERMIT SAN JOAQUIN COUNTY PURL/C f1F:ALTS SERVICES i' ENVIRONMENTAL HEALTH LIVISION 1601 E. 2AZELTON AVE. , PRONE (209)468-3426 r P O UOX 2009, STOCKTON, CA 95201 ktt� PERMIT EXP? 1 IFAR FRQK_DAjh__l: `,11:'2 s (Complete ].n Triplicate) Application Is here:ry made.to San Jenquin County Car a perrlt tr construct andlor Instal'. the v,,rk herein described. Thla x� c application is wade 1n coagliance vith San Joaqulr County Ordint.ace Mo. 564 an! 1862 and the Rules and ;regulations or lien ifs Joaquin County F'ublt c Health Sery;viss. C.� Job Address _ f -1" __ _ City�-_�<- let Size/Acreage Owner's Name_�L-F' �dR_i�r.�SE?il!�__ Address Z2.x.L/_,.,-�5G'0 r. Ph Phone N r't.� Phone .,Q,g?-/ ContraclOr,�Gr� Address-Z SL,�L?,EE- reT ..,��?_I..LitensrNo.�jl'r7L none TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION O.Out or P711ca Vr1I PUMP INSTALLATION ❑ SYSTEM REPAIR E7 O'HER Ll t/onito:lIng Ye11 L7 t Y DISTANCE TO NEAREST: SEPTIC TANK !i2WFR LINES _ w DISPOSAL FLO. PROP.LINE FOUNDATION �. AGRICULTURE WELL OTHER WELL PITS/SUMPS ." INTENDED USE TYPE OF WELL PR�LEMAREA CONSTRUCTION SPECIFICATIONS C-]Industrial Cl Open Bottom ❑Mah ace Dra.0 Well Eecavolion�� nls.of Watt Casing E.t Dameatic/Private Cl Gravel Peck L.7 Tracy lip•of Cnmq �_�, Spetrlicallons I'I Public fa Other fl Dan Depth of Glwo :'.4181 type of Grout - I I Irrigation --Apreox. Depth I astern Surface Saul Invh4d by _ - iiepair Work Done 0 Type of Pump Il.P., - Stara Work Dona I Scali terlal 4 D-.pin 3 Well Destruction ❑ Well Diamels� ----------- N Depth tiller >,r.tcrtal Z depth_ e n } TYPE OF SEPTIC WORK: NEN/INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo saplic system permuteC if public sewer is v i available within 200 last.) ' R a z Installation wilt serve: Residence Commercial,_ Other Number of living units:�_ Number of bedrooms _ Character of soil to a depth of 3 lest:.- _SO VD f !eW try _ —t Vater labia depth SEPTIC TANK 0�Type/Mf C.G—P91- Cp r. tpacrty�� No.Compenments t PKG. TREt.TMENT PLT,0 Methcd of Dunne! -' 1 r -l_� ' Properly Lind -,'7.� Uisunca Ea nearest: Well �O Foundation— z 1 " 1} LEACHING LINE UK No.d Length of lines TatTr lengthJsire_ c^^ FILTER BED CI 01SranGe to nearest: Well / 1"� Foundelwn N� r PrnpeRy Line r ---- ? SEEPAGE PITS I! DepthSire �,�.. Number_ SUMPS LI Distance to nearest: Well Fr,undasron.-_.. Property Lina DISPOSRJ.PONDS 0 -ao r w1 1 r 1 hereby Canify that i have prepared this application and that the work wd;he dons in accordeoce with San Joaquin county ordinances,slate laws,and` a r + rules and rsgulalions of the San Joaquin County \� - Home owner or licensed agent's signature Collies the following;•'t certify than tit rhe padarmanco of the work for which this permit is issued,I"it nut r ,> employ any parson in such manner as to become subject to wo:keian's comoonaatron laws of California."rontrsctor's hiring of sub-contracting signature certifies the Iollowing:"I certify that in the performance of the weirk for which she permit is issudd,101.611 smoloy persona subject to workman's cornpanas• ` tion laws of California." The applicant must call for all rersuue,:inapgctionx. Colnplwe drawing an raserse Bide, ., ., Signed �._.��r"" `5��--- Tito: ��7LGLs....._.. Date: Z. FOR DEPARTMENT USE ONLY Applicatlorr,Accepted by 1-1 Data`f 2-r ,_ _ ... Data�. _ ,� ra Arae—I- Pit I 'mr _ Pit or Grout Inspection by Dote FPAsI Inspection by Delia �V t vy Additional Comrnems: Applicant - Return all cop%ea to: San Joaquin County Publtc Henith Eervlces, Environmental Health Perul.t/Service, 1601 E. Hazelton Ave., P 0 Bax 2009, Stockton, CA 95201 INFO AMEIVED BY AMOUNT DUE AMOUNT REMITTED t DATE PERMtT NO. rv,r. [i 1 H[C ,ry a Fitt]-]rlrttv.rr�S! `'T .0() U .=E�7�Z- 4-2:/�1D ��r�••%3 3