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APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1445 N SAN JOAQUIN, PHONE (209)468-3420 ePe P O BOX 2009, STOCKTON, CA 95201b J N,, ERld TE%PI RES YE FR lI[ D E S .,,.{C? 3 19,92 f F, �, (Complete in Triplicate) cr+,•'�•f ; . LlCrLEE4 , .�C,;../�r�, work her Application is hereby ands to San:Josquin County for a 1pl� �+� application is made in cot�lianec with San Joaquin County Ordinance No. 549aand o1862 and the install eRules and-7t_1. Hegulation o Bane Joaquin County Public Health Services. Job Address 3 7 ?S` Baty evwrO City _O_r_ Lot Size/Acreage fS"�a�P,�x1 Owner's Name UVIDGC- c Ora-429n Address 2eco C1 c- m on Plwc�S.4 Wrre Phone '71 27-1-Z-3sy 5A-n Aa.noi,,CA9Nr s3 r!.c1. e.- 2.7.E Rv 9 S/w.od e...d Contractor n W&s# Co. rr+c. Address o n a License No.SJOo1CS. `Phan 9/6 662--ZSAS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION Out of Service Kell ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ '� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ($-- A#4�1.� Dnn�tdm, 0 Industrial O Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing ? t l Domestic/Private ❑ Gravel Pack ❑ Trac T ! V Type of Casing— ('I I'I Public CSpecifications l Other FI Delta Depth of Grout Seal Type fi Grout- Repair I Irrigation A —. pprox, Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done ell Destruction Well Diameter Z lnc.jt Sealing Material A Depth Depth 20 +, Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation available within 200 feet.)ation will sante: Residence� Comercial� Other_ - Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compantments M PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE L1 No. & Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth t Sire Number F SUMPS LI Distance to nearest: Well FoundationI DISPOSAL PONDS ❑ ------ Property Lina I 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 rules and regulalkx%of the San Joaquin County 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 parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ceonif� fCgowi l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's eompensa- The applicant must call for ail required inspections. Complete drawing on reverse side. &e. A#��i St+c- P��.�) Signed ckt., Title: a„or Date: ./I i?�R .*r 4Aret� .(sem.u+i.�+, d A'�s...t=., ,rr carp- r,�w FOR DEPARTMENT USE ONLY Y Application Accepted by Date p Area Pit or Grout Inspection by • Date �./ Z`f Z Final Inspection by Date ! �/ Additional Comments: ` I �, Applicant - Return all copies Sea Joaquin County Public Health Services Snvirontnental Healt4 Permit/Services tt0 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 u 4 FEE AMOUNT DUE i AMOUNT REMiTTEO p INFO CASH RECEIVED BY DATE PERMIT'N0. . EN 1 7.24 IIIEY.t/A 51 t G 16 y� ILul VC_ EM 14•7a F