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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 �`i N©0 ��/O PERMIT EIRES I YEAR FROM DATE ISSUED tU0 8L �� 173 (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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. VJob Address m ^ �O � � �� City 9 ((.A-/ ,A Lot Size/Acreage Owner's Name _��t a f�.�,,�rein Address J6 13Phone CG 5` GW t T_e61-�`C'e AConlractar Address License No b T 3 3 Phone,9 - TYPE L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E - OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: S � ANK SEWER LINES DISPOSAL TLD. P. LINE FOUNDATIO AGRICULTURE WELL ELL PITS/SUMPS INTENDED USE "TYPE OF WELL PR ONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia, of Well Casing Cl Domestic/Private ❑ ack O Tracy Type asing_ Specifications 1'} Public El Other Cl Delta Depth of Gro at Type of Grout 1 I Irrigati _Approx. Depth I I Eastern Surface Seal Insialle R tr Work Done 0 Type of Pump H.P. State Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I 1 DESTRUCTION/X INo septic system permuted it public rawer is Installation will serve: Residence— Commercial— Other available within 200 lest.i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 l Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sta rules and regulations of the San Joaquin County to laws, and 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 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 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant call i all r wired inspections. Complete drawing on reverse side. XSigned Title: Date: _ZA2 ,��_-�/ FORDEPARTMENT USE ONLY Application Accepted by • Date 4u Area i Pit or Grout inspection by 11 Data Final Inspection by � pate 7`1'�T2 Additional Comments: ars t �n e l N.�a [ CJ o•, ` �{� Z-27 -- r Applicant - Return all copies o: San Joaquin County Public Health Services o2 �!/VL�c r j t•+� CP ouf Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO 4''f7 �� (7Y !.-l7COASRECEIVED 9Y 1H ) OATE PERMiT'NO. • EN 14.26EM 13-24 IREV.rinss SR 1 •D0