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APPLICATION FOR PERYI SAN JOAQUIN COUNTS PUBLIC VICT'�Z� ENVIRONMENTAL HEALTH I u.,V 445 N SAN JOAQUIN, PHONE ( 3420 P O BOX 2009, STOCKTON, CAP AYEAR (Complete in Tripli ate Apyllcatloo 1a hereby rade to Baa Joaquin County ror a permit to construct 7 rrein described. This application 1s ode in cospllanCe with Dan Joaquin County Ordinance No. 51,9 and IW and the Rules and RegulLtlons o: Sari Josquia County PQubl!^ HealthlLS�e-rvv'iicc�es�.� Rw..�� Job Address '�2`� F i ti.t •`�+'ti �'-, city 11� + Lot site/Acresae 1 2 f(/� ?�3 0(d i Ownw's Nacre + `TR. 7� �,P9 l ti�A Pho �y— Addreu - 1 0� aD� � Address License No. Prone +♦ 7YPE OF WEL UM NEW WELL C WELL REPLACEMENT L-1 DESTRUCTION U Out of Service vol= , E PUMP INSTALLATION C SYSTEM REPAIR ^ OTHER O Monitoring vcll ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPCSAL FLO. PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL AliS I S INTENCED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF'CATIONS a a : ❑ Industria! Cl❑Open Bottom ❑ Mannca bra.of Wall Excavation n Oomestic/Private ❑Gavle Pack C Tracy Type of Calling 'Ir'tlpeglL�> 7 - I'1 Pudk f-1 Other n Deita Depth of Grout Soal SAN�O GegNr,�__ — - l Vl'fV f Y ii I I Illigallbn Approa. Depth 1 I Eastern Surface heal InaialEed by PUB Rapes Wort Ohne U Type of Pump H.P. .hare �. 7 Wed Destruction ❑ - Well Diarnater Sealing laaterlal a WyW c. { ' )liter ltatarial a Depth r 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAiA/ DOfTION DE$7RU :TIO ileo MprrC sYaram permned d grbhc ares u ai18We vnthin 200 feet.) CNO Installation wilt serve: Residence_ Commercial bthw Number of YvnQ units: PumblN o 1 T y.:�:•+,'3'+ �.1�t% ?r:i-;__� Chwacw of"to a depth of D feet: , - --Wates table depth SEPTIC TANK. Type/Mfg No. Cornpartlrents }e.� �y�'.r. _ PKG.TREATMENT PLT.❑ f / ` - MerthrA of Disposal R. xl� Distance to nearest: Weal Q Cy Foundation d`} Pr r�}- ,a Property line ♦'„ zr+ira +N,'rjt- LEACHING LINE No. 8 L"th of;inns _ L1—SQ Tota!IangM/aixe FILTER BED Q 0latanca to nearest: Wdll_ Foundation,�L��I�' Property line S r w #f ,r SEEPAGE PITS DeFtn _Sit, _y Number r SUMPS LI Diatancs to newest: Well Foundation �r+ Property Line .r7 DISPOSAL PONDS ❑ /cra `1 hereby Certify that I have prepared this application and that the work wig be done in accordance with San Joaquin county ordinances, stats paves,and rules and rep}arbrr of the San Joaq-tm County - 4%�!Jfi,a.s .�.' 1lorrre o",~or licensedegent'a siprsatun aertr!ise the loaowrng:"I cattily that in the performance of the work for which anis pwmt Lr issued,I Nae not '`. - tlmDioY any petition in Much~her as to became subject to workman's compensation Wes of California."Contractoes hiring at sub-cuntracting signsturs ' �..t•�'. Eertlfles the I,aFowrirsq:"I tsrtih that M the performance of the work for permit is this peris issued,I shat:eWeorn subject to wtfttman'a tampon tion pew of CaWorn e." The appGcard must- If ad required inspections- Complete drawing on reverse sada. 4 T-Yr �+I--h.r t •, Spared r 'kle: �l.l>•'y\4 lam. Date: 15 11 AA 9q i FOR DEPARTMENT USE ONLY , AppMutlon Accepted by Data Area 31 Ph or Grout inspection by Oats Final Inspection Dy Date � aH�; }. •. .. Additional Camnwu: ` t Owl ADP1Scaet - Return all copies to: San Joaqu: County blit (i Services Soviroes*ental Health Plimit/9ervicee '' +n�fi' 613 N San Joaquin, P O Box 2009, otke, CA 96201 { �.lJr'r,t,•..- .- rt 7,G;•.,`. l(..�JFEE AaVgONT 011E •MOl1NT REMITTED CASH KECENEO By OAT[ vtrt MlT'Np. ~ / I INFO r i. i EM,sts(REV.,,ser IN 14-311 "1 ; J 7 'fid✓/ ��+ '�"ntL" •af+ p� n..i ...... . .. ... � .. _._.....�.�_..- .. ...' ....__.,,rte• i