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FAX SENT #PGs TO 1 IOerPAPW 5 .411V,6411- DATE 6 Z PPLICATION FOR PERMIT FAX# Cl I'Zy 1Z, TIME 12:2- COUNTY PUBLIC HEALTH SERVICES s NMENTAL HEALTH DIVISION SENTt3Y AVERY FX-10S TOAQUIN, PHONE (209)468-3420 i 20091 STOCKTON, CA 95201 AMIl fit T EXPIRES I YE ' FR M DATE ISSUM (Complete in Triplicate) Application is hereby cade,to San'Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health ervices. �1,s'""��Jf ' ,. Job Address = P%z, —zv CityC-� hem/Acreage Owner's NameT t/V- f r� dra4 ss ( ��-!/. !/f//!/ f/'Y3 �3 10 Phone j Contractor 1. Address License No.lyff_Z�6 Phone TYPE OF WELL/PUMP:" 3, _ N W WELL1 a^_ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Yell ❑ t_. PUMP.INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well CZ DISTANCE TO NEAREST: SEPTIC TANK - S_EWEA LINES DISPOSAL FLO. r— PROP. LINE •�gd ! `.FOUNDATION ,✓--4 AGRICULTURE WELLOTHER WELL ITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS —n Industrial // r �:.. , ,, ❑ Open,Bottom O'•Manteta,'�* Dia.'of;Weil Ekcavati `7 Dla. of Weil Casin f!IC f.] Domestic/Private ravel,Pack n Tracy _ Type of Casin C� _ _ 9- Specifications "f'3 Public f1,0_1 r pelta�._�_. _Depth Grout Seal Ypa _ _ _ of Grout _K IrriYation%1 a.,. Appro>t rQeprh I 1 tcaiiern t<.Surfaca Seal Installed by r ►RepanWork Done-��'�U -Type of Pump H P Stets Work Done_ Well Destruction ❑ Well Diameter lSealing Material i Depth Depth 1 t Tiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 i REPAIR/ADDITION f I DESTRUCTION l I (No septic system permitted it public sewer is )a available within 200 feet.) Installation will Terve: Residence_ Commercial Other Numbarbf living units: Number of bedrooms Charectill of wd to a depth of 3 feet: } Water table depth 4 �1 SEPTIC TANK. : ❑ Type/Mfg i l Capacity PKG. TREATNo. Compartments MENT PLT._0 , Method of Disposal � Distance to nearest: Well Foundation Property Lina t LEACHING,LINE� ❑ No.6 Length of linea Torti!-length/size FILTER BED ,,. O Distanceto nearest: Well Foundation Property Line SEEPAGE PITSpp I I MDepth Size Numbs +SUMPS LI! Diitan a to nearest: Well Foundation. Property Line DISPOSAL PONDS ❑ i I hereby certify that 1 have prepared this applicationLantlthat.the, ork will be done in accordance with San Joaquin county ordinances, state rules and ragulei him of the San Joaquin County " ' laws, and Home owner or,kensed agent's,aignatursCertifies tfie=:following:,q:l,certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as,to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following. "I cartify:that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- 1 t!on laws of California." r The applicant 1'raquir s. Complete drawing on rev ide. Signed J ills' Date: ; � FOR DEPARTMENT USE ONLY Application. cceptad by,.- ^- . J r Data Area Pit or Inspection by Z ��Date - Final Inspection by Data ! y .. Addltloru! Commtihts: � !`�•' 01` Applicant - Return-all' copie ` to:x San Joaquin County Public Health Services Environmental Health Permit/Services ,....,.445,.N-San_Joaquin,,...P..0.Box.2009,_Stknm,-CA-85201 I I/NSF/O{ AMOUNT'b ' 3 AMOUNT REMITTED K "f RECEIVED BY ATE PERMIT'NO. •'E.N't}2�'rIIEV'1/R'S)�^�/l/... �� / _ . ..n .-^y..urw w�r...w. .vl- «�r +w+, !�. meas Eir 11->!p � �~