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APPLICATION fj^^N I SAN JOAQUIN COUNTY PUBLIC AyJTj{ SERVICES 50 0 ENVIRONMENTAL HEALTH YII�I�It 445 N SAN JOAQUIN, PHONE ( )'ds�y,R-9420 P O BOR 2009, STOC%TON, advni PERMIT EXPIRES � (Complete in Tripli Application is hereby eadelo, San Joaquin County -or a Ps'rnit to construct And/or Install tl.e vork herein described. Thle application to ,ads In etseplianee vith San Joaquin County Oralnance No. 549 end 1862 and the Rules and Resulationa of Pam Joaquin County Public Health Services. S(DO 3 .4.y� 6 Jeb Ade�.EF I/�` 555'o�RO c„y_fit-�L wt Sl Fr/A<reege Owren a N.mayl.�U tl r/�nlr>• �.lst�-S Add,e,s te e_ Phan. �3a�efdo5 Contractor r•r,�- I("(` Address_�Q 6X (vS6 License No.� V, Phone a3'1`"7)73 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION Ll Out of Servlce Ne11 ❑ P PUMP INSTALLATION CI SYSTEM REPAIR -I OTHER ❑ Itonitarl 111, 71 ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.__ PROP. LINE .. FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS --a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Induatnel ❑,Open Bottom ❑M.ntace Dia of Well Excavation Dia.of Weft Casing '! CI Domestic/filw.e ❑G,NA1 Pack '❑ Tracy------TYDa of Casing_ $pecil(catims PI Public rVothar fl Dllu- Depth.1 Gmul Seal .r Type of Grout �..�. I I brpahon ADMonI Depth I)Eastern Surface Seel Installed by Repair Work Done ❑ Type of Pump, ""xtl----I _ Sou Work Da7a WW Destruction ❑ WHI Di.mata .-Sealing l4eerl+i.A Depth. E IOeptlt-. J_� Filer 14ter1al A Depth TYPE OF SEPTIC WORK: NEW INSL}LLA I11—- —REPAIRIADOITION DESTRUCTION I IIno pplp ryaum permmw it qbl¢aYWar q ' _ avaBaole within 200 last.) �4 to commercial w TAluldenu commemul_ Our., Number.1 Sang uniteI_ t Number of bedrooms M C:.arsetM of eon to•depth of lel ANrb.P_ W.Ier table depth SEPTIC TANK TypbeMpt=l No.'�Cpmpartm.nn l PKO. TREATMENT PLT,❑ Method of 0Neou1 Generic,to rreuest Well��_ Foundation Property Luta I 1 _ — 3 LEACHING LINE 4l�Na.b Length of line — D O Total length/site FILTER BED ❑ 'Distance to nearest: Well l p R Founpau0n I PropeM Lina SIJ_ Z-' SEEPAGE PITS I I Instill, t _ . Dep Sir. _ Number .. ' .-SUMPS LI Distance to Merest: Well Foundation Property Lina DISPOSAL PONDS ❑ I I I I i'sraby cagily that I have prepared this application and rat the work will bo don.in accordan a with San Joaquin county olrRnaneo,sots laws,AM Ship t l ' Well aregulations of the San Joaquin County Noma owner or,Ibemafollowing:d agent'.signature unitive the follong:"I cortily that in the yiformm�A of the work tun which this permit is iuivad,I than net employ any parson in such m.nrer as I.become.ubpct I.worf,"n's compensation g4 of Caforms."Contractors hiring or sutocce flacting signature ...MnMw the following. 'I Comely that in the performance of the work to Ich this permit is issued;I alull employ parson.sutocl to v trrtman i compensa I r...00.LAAAA of CalNomia.•' f The applicant moat call for W r uirad .c'wetiona. DOTpiAle duwino on reverse oda." t----- I Signed x Tito:_ F'�t-� Date C I I/'� .,��FO�RR DEPARTMENT USE ONLY Application Accepted by ` {]..[++ If rM�f' —” Date AN. C PM or Grout Iregctbn by Dae Final Inspection by xZf Dee r r 7'-t2 Add4bref Comments: Appl leant - Return ell coplon to: Sen Joaquin County PooIfc Heath SerYiC.. - fh Snvlr...A.tel Health Farmlt/Seryl Cee 1 4.5 N San Joaquin, P O Ron 2009, Stan, CA 95201 ',tQ AMOUNT DUE AMOUNT RFMRTED ^SR RECEIVED ay `1 ' Y(C� DATE PERMIT'M0. M utv i4 �� 4'3Gr mac- (y/mr, .00tg0 1eH 4 ..0 �. , Awa