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I _ APPLICATION SAN JOAQUIN COUNTY PUBLICEHVICES ENVIRONMENTAL HEALTH D 445 N SAN JOAQUIN, PHONE ' 8-3420 P O BOX 2009, STOCBTO , }�1JJ PERMIT EXPIRES 1 YEAR FR( MF (Complete in Trip '1W 0 Application is hereby made to San Joaquin County for a permit to const ��Y ft eecrlbed. This application to made in compliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation. of San Joaquin County Public Health Services. Job Addressra�f' Y 3 `// E /^jrU, s e City Lot Size/Acreage -7 Owner's Name,/ye r- G t\ Address zJs 3-7 ^ F /� /'- b� / Contractor / L/� S Address Z _ ' /'rLC; /i License No. 732- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 n Industrial ❑ Open Bottom ❑ Mantes Dia. of Well Excavation DID. of Well Casing �F Dom"110Privale ❑ Gravel Pack ❑ Tracy Type of Casing_.__ Specifications 1'I PllbliC 11 Other fl Delta Depth of Grout Seal Type of Grout I I Urgahon _ Approx. Depth I I Easton Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Oona _ Wall Dnvuction ❑ Well Diameter Sealing Material a Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 Met septic system parmined it public server is available within 200 lest.) Installation will sena. Residence_ Commercial _ Other vJ Number of living unite _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— a PKG. TREATMENT PLf�fJa,T.❑ E_If6e'Atl* Distance to nearest: Well Foundation Pro FEB 0 199; LEACHING LINE ❑ No. g Length of lines Total tannin/Ai¢� FILTER BED ❑ Distance to nearest WWI FoundatgnUUNTY —_,rirtf ` FNyiRONMEN,TjjI SEEPAGE PITS 11 Depth Site Number SUMPS LI Distance to neared: Well Foundation Property Lina DISPOSAL PONDS O I hereby canify that I have prepared this application and that the work will be done in accordance wish San Joaquin county ordinances, stale laws, and rules and regulations of Ine San Joaquin County Home Owner or licensed agent's.ignemre caniffes 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 compenedlion 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 ccmpensa tion laws of California." The applicant mu c I for at required a ions. Complete drawing on reverse side. Signed X y kiN Title: Sr>_ /'r/rC e 41 Aid 92L-ii Date: -_7 �3'-• FOR DEPARTMENT USE ONLY Application Accepted by Date44— Apart i Pit or Grout Impaction by Data Final Inspection haiDna Additional Comments: Appllcant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit Services 2 445 N San Joaquin, P O Box 2009, Slice, CA it 201 ,J10 INFO AMOUNT DOE AMOUNT REMITTED C H RECEIVED BY D�cTE— -PERMir NO. . EN 1!2`1 AV rr." FqsC � I�lPo' i