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`�', APPLICATION FOR PERMIT, 'I Iftliil i pi i J-JJOAQUIN COUW Y PUBLIC HFALT . VICES ENVIRO#MENTAL HEALTH DIVISION 445 N SAN- JOAQUIN. PHONE (209.)468-3420 Ll P O�_W+X '.;2009, STOCKTON, CA 95201 T!=III ] FROM III ISSUED 1' (Co*1ete is Triplicate) Application Is hereby made to San Joaquin County for a permit to to construct and/or install the vork berein described- 'This application is made in ca�liance with San Joaquin)!County Ordinance No. 549 and 1862 and the Rules and Regulations of:;'San Joaquin County Public health Services. 'i �; 'i /� J 1 :. I: i SfferrFti Job Address rIQ�'d�7.Q�QY 4H0 (U17G�LC/'V.�� ___ City Lot Size cre i Owner's Name )6waw �QfilDlrG +t DT� '�Addiess �• f f 3 C 9 SLo l phone Zd Z06 - Add, //. C�� Oji' I. j 582041 707-7jlSt 09 Contractor 3;;15 �G1PQ7lAA►yq�L1C S Address' 0'i Bax License No. f hone TYPE OF WELL/PUMP: NEW WELL ❑ i; I WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ I.j SYSTEM REPAIR ❑ OTHER : tAonitoring Yell Vape rair$'r'aaiiowcL�S DISTANCE TO NEAREST: SEPTIC TANK f;j "' ;SEWER LINES DISPOSAL FLO.�R PROP. LINE �` FOUNDATION o� '= ' 'AGRICULTURE WELLS OTHER WELL PITS/SUMPS It i 1 INTENDED USE TYPE OF WELL i R09LEIkE'i.REA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ open Bottom ❑ Man:ieca, Dia, of Well Excavation to„.el.aS Dia. of Well Casing 21 'i t-) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ PyC Specifications t'I Public n other rl tDelta ; Depth of Grout Seal H rC,.t- Type of Grou h/e� I I Irrigation !Approx. Depth I I Eastern Surface Seal installed by i Repair Work Done ❑ Typo of Pump H.,P. State Work Dora (; 'Sealing Material i Depth Wall Destruction p Well Diameter �) , 'E Depth I �, ;Tiller Material i Depth i TYPE OF SEPTIC WORK; NEW INSTALLATION I I i REPAIfaiADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is yavailable within 206 feet.) Installation will serve: Residents_ Commercial!_! '] Other j Number of living units: Number of bedroanms J.?) Character of molt to s depth of 3 fast: 9 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` € PKG. TREATMENT PLT.❑ Method of Disposal a I Distance to nearest: ',#Welt Foundation Property Line LEACHING LINE Cl No. E Length of lines M:r 4j length/size j FILTER BED 0 Distance to nearest: ,�GNell � Foundation Property Line r SEEPAGE PITS I I Depth I'I'SNumber i SUMPS L1 Distance to nearest „1Nell Foundation Property Linc r DISPOSAL PONDS O I 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 reputations of the San Joaquin County Home owner or licensed agent's signature conifies the folldwing: I certify that in the performance of the work for which this perrtrt is issued. I shall not I employ any person in such manner as to become subject to w Ihman's compensation 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 compensa- tion laws of "iforrtle." The applicant o ! nqu in a. Completel',drowing on reverse side. aE,jl: .1 :I S r I Spred Title: ,/3"r r�.r.,�1c. / Date: �, i FOR DEPARTMENT USE ONLY Application Accepted by �r P-n�A r::.. I - — Date_ S Area` U -'I Ph w Grout Inspection by ''Date ''' final Inspection by Date Additional Comr+msnts. Applicant - Return all copies to: San 01 County Public Health Services 73 a:U rnviroprneetal Health Permit/Servicer 445;N''SaalJoaquin, P O box 2009, Stkn, CA 95201 i � ,k. I FEE INFO AMOUNT DUE AMOUNT.REMITTED CASH RECEIVED GY DATE PRMIT'NO. EK 1124 rasa+.lsrI�-IL. OO,S 2.� • fK 14-7e - {,