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APPLICATION c �J SAN JOAQUIN COUNTY PUBLIC SERVIC160 ENVIRONMENTAL HEALTH I}(;�S ON �7 445 N SAN JOAQUIN, PHONE ( ) 6'5-3420 it P O BOX 2009, STOCXTON,JCA 95201 ' J PERMIT EXPIRES 1 YEAR FROM DATE IS (Complete in Triplicate) �-N� Application is hereby made to San Joaquin County for a permit to construct and/or ineiel2 t his 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. !J Job Address .1 :Y 00 (0—/9�'�P .�C ��_� City rAl` L1 ,/��M 01` �7 . S1 ze/Acreage `y 4(l e T Owner's Name D ,Ve- "RI!07✓/ Address c� Y3-5- `mL/if;I,&,'�J'� ( Oa�1%. Phone —Y Contractor S3f�1a1¢��e f,' sN�✓//iddress '.S' Jac{ (fLr's'license No. -Pu7 Q Phone-f> TYPf,OF WELL/PUMP. NEW WELLWELL REPLACEMENT Cl DESTRUCTION ClOut of Service W ❑ 9ao - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitori ell ❑ ISISTANCE T AR ST: SEPTI ANN S R LINES DISPOS PROP. der (�� O DATION AGR IC ELL J R WELL .'✓i. _ /SUMPS _ J INTENDED USE TYPE ELL PROBLEM AREA CONSTRUCTION SPECIFICATION l\�I ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing G.YDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (� I') Public ❑ Other fl Delta De ut Seal Type of Grout \J I I Imitation APMox. De th Surface Seal Installs Repair Work Don ype of Pump H.P. State Work Done _ estructlon ❑ Well Diameter Sealing Material L Depth J Depth Filler Material a Depth (�n TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public "we, is available within 200 feet.) Installation will some: Residence_L Commercial_ Oth �>er _ IX tl ie- Number of living units: —/-- Number of bedrooms— Character of soil to a depth of 3 leer: Water table depth SEPTIC TANK ❑ Type/Mfg-76 /'L�� Capacity ��'MG No. Compartments PKG. TREATMENT PLT. ❑ n � Methodoqf Disposal Distance to nearest: Well s , Foundation � Property Line`�- LEACHING LINE Cl No. b Length of lines � �� Total length/size FILTER BED ❑ Distance to nearest: Well _9y-r.��L- Foundation -.Z.0 Property Line SEEPAGE PITS 11 Depth 13� Size .3 3 _ Number c� SUMPS LI Distance to nearest: Well 'Vit49 �e_- Foundation A 'J(' Property Line !Ud f DISPOSAL PONDS ❑ 1 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 regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I cenify 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 workmen's compensation laws or California." Contractor's hiring or sub-contracting signature clarifies 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 applrca at call for all requi inspections. Complete drawing on reverse side. ) /' C� Signed;Ms '� MZ Title: �GC) 9V ami Date: 7 '.,�/ I FOR DEPARTMENT USE ONLY Application Accepted by Date �P(.pr Grout Inspection by j Data 7 Final Inspection by Date 27 Addif5nal Comments Applicant - Return all copies to: San Joaquin County Public Health Services Env445 N San tel Health Permit/Services StI 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 NFO AMOUNT DUE`` AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT'NO. EH I a]4IeEV.lrn EN I6le �l / . !/V✓ �`. L// /� �/�� (/�/ J ✓Y' /