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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SIMI ENVIRONMENTAL HEALTH DIVI 0111n 445 N SAN JOAQUIN, PHONE (209) 0'/�..a P O BOX 2009, STOCKTON, C9 „� '�/ ✓J�— 2r� 'fti!;�„►�r�1 PEMIT PS 1 YEAR FR (Complete in Triplicat )INV Appllcetlos is herchy made,w Sao Joaquin County ror a permit to construct an )INV "ib� he sit deacribed. a allplicatlon ie a"* is wmpllasee with San Joaquin County Ordinance So. 549 and 1662 aVu me or Sao Joaguln COunty Pub11C liddittl 80rvlcea. Joh Address A• / V 6 .�9 �t r(dwdee/ t►A cap STeeb'T/,tv Let size/Acreage owner's Name "'O"relf 1/i eYYA Address S'A1ILt _ Phone Contracter Address db ye /1 D License No.yyy'$9/ Phone9'f 1A 3 TYPE OF WELLIPUMP, NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Vell PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Nocitcrl04 Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP_ LINE FOUNDATION AGRICULTURE WELL OTHER WELL PiTSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ CI Industrial ❑Open Bottom Iff Maniacs Die, of Wad Eacaratien_ Dia. of Wag Casing Cl Doma"4l"rivate ❑ Gravel Pack ❑ Tracy Type of Casino_ Spscdicatioro VI Public tl Other n Dalin Depth.of Glout Seal Type of Grout I I Init lion _Apprott. Oepth ( I Eastern Surfaoa Saw Insteilad by 0 � Repo✓work Done 0 Type of Pump H.P. State work Ogrna, Wed Destruction 0 Well Diamettar Saalltsli Haterial 6 Depth Depth Piller lastari&1 i. Depth TYPE OF SEPTIC WORK, NEW LNSTALLATION 1.1 REPAIR/AOOITION XF DESTRUCTION 1 I (No septic system permitted if public-ewer is • larvawadable within 200 feat.) Irotaaatcn aril : Readenca_(__ Commercial, Other Number Of bwV Wkc Number of bedrooms Character Ot aoa q•depth of feet: .. G G w y Watw table depth OY • a` SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ • ,,Method of Disposal oistanu to nearest: Weis- - Foundation _ Prop�lty Lina LEACHING UNE 0 No. 6 Length of firm f'0 ♦ Intal length/size 1414 FILTER BED ❑ Distance to naerew Wall /!T >-V _ Propry Lir 5'* SEEPAGE PITS y1 Depth RSA �gw,_ yA"r CJA Number. l SUMPS LI Distance to avast: WON .000' 'Foundation �- Prop"Lw DISPOSAL PONDS ❑ 1 hereby cattily Chet I Mw prepared this application and that the work wU ba Aare lit acewdanu with Soh Joe nulls and ragulatiorr of the San Joaquin Crusty �' qua county wihrrances, state Laws, aro Hoer owner w Ireanead agant's 09"ture cenif"the following: "t oartify that in the peAorrrrnca of the work for which this Permit La issued, 1 shall nol wr'PlOy any 011100 in such mama as to become subpc,o workman-,compensation laws of CelHorrda.-Con,ractot's hking w sub-controctirtg signature 0"feas ON ton leas of Nl w * I rarefy that in the performance of the work iw v!fch this permit u issued,I"I employ paaptl subject to wwkmat a cor peMa- The apphicartt tW for all rWutnd inapttctions. Complete drawing on reverse aide. Spud >L Jr�� e/sr, rL`-V—'Qsi.� --- nor: Data: FOR DEPARTMENT USE ONLY AppEcetlon Accepted b`/ Dau f f tea� 1 tv4mctlo0 W �ft��t Dr'0nrsants: Applicant - Return all copies tat San Joaquin County Public Health Services -- Nov nsiontal Health . \ ces 4451IsoSan Joaquin. p O oat1009,iStto, GA 9 O1 {'t FEE AMOUNT DUE AMOUNT R rtTEO J O O ..�.- ..... _. , MIFO - _ CMA5114 RECWED 6Y .DATE fir ��A/f�/ (j(, . l}salaN,1/oat 0 DJ -..•r+ M