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- . .R— «a,...�,...,.,r�l.. « � •• •^[- .,�w.. �fr, +�- �r-r.......,._� ..�,.:�.�e+..�� ,x,r-_�-,...r_.,.A,,•.�..,ar:.� :-iF'-* =--w�T-i-$-_.:- .. �ti SANIAQQIN COUNTY PUBLIC HEAT TF!r `ERVICES ENV IS AMENTAL HEALTH DIVI gT& 445 N SN -3420, HOS (209 4 68 POIJBOg 2009t STOCKTON; CA 95201 , T EXP I't f ;('Ggtnplete in Triplicate);. Application is hereby made to Sen Joaquin Countyfpll r a permit to construct and/or instal the vork herein described. This application is made in compliance with San ill .. V1 County Ordinate Ho. 549 and 1!8b2.and the Rules and Regulations of San Joaquin County Public Health Services. II[; ( h- 1 �I Job Address f�A 21�/NtJ lk y CYYI f LN • City T7SCkl ]!V Lot Size/Acreage K 2-10Y i'�yl( :k GeN Ci�Gf AC VI f L C� ?G(7. Z 57� 7� , CP +er..l.c:_. ;irii,. S'(UIC.�.v � Phon 5 ;:JD LCi rl Owner a Name R� Add . ��X f l�� a� I .--- ' ' rbc1 e fit;s r&71 Z Contractor �� '77Zurv� f�1C�I��S�J1l2�1ddress! .��''2 � E.1�1`IIZ� S. icense No. 5� 22� _Phone( TYPE OF WELL/PUMP: NEW WELL - !' WELL REPLACEMENT L DESTRUCTION ❑ taut or Service Well ❑ '! PUMP INSTALLATION 0 III SYSTEM REPAIR ❑ •!' OTHER ❑ Motiitorittg (fell DISTANCE TO NEAREST: SEPTIC TANK 7 9b1OF SEWER LINES � � DISPOSAL FLD.y�- PROP. LINE l: FOUNDATION 2M JT11, ;AGpICULTURE WELL OTktR WELL-Zj-Q— PITS/SUMPS f' k lk INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom ❑ Maniec Dia. of Wall Excavation Dia: of Weil Casing Domestic/Priv t Cl Gravel Pack ❑ Treey rl Type of Casing �� lI Specifications U MoN 1 r� .rllia �,.;: r 4 ('I Public 100 r n Delta ;. Depth of Grout Seal ��• ;s T�Pa of Grout N�t �' l �A'r4rory rrn�,N 6 p S EC�'rYd ry [ 1 1 Irrigation Approx. Depth f Easuin Surface Seal Installed by Repair Work Done LJ Type of Pump H;P, State[WorkDone Well Destruction O Well Diameter ;i; (Sealing Material & Depth Depth !IA i3 Tiller Material i Depth a. TYPE OF SEPTIC WORK: NEW INSTALLATION I ftj f:,aEPAIR/ADDITION I I DESTRUCTION I I ANo septic system permitted if public sewer is ,available within x00 feat.) r a Installation will serve: Residents_ Commercial 0_,1- ibther Fr } Number of living units: Number of bedroo ` Character of sop to a depth of 3 fit; l iii, I I!1 Ps9Ylt�th ' : bl t Ij .l€: �A� SEPTIC TANK. ❑ Type/IVlig Capacity PKG. TREATMENT PLT.❑ I `t I I 1,,� � A 1� IL r Distance to nearest.arest: Welt i. Foundation ' . Pr-opJe�rty Lr i +t'r IJk N AAQUIN COUNT LEACHING LINE Ll No. A Length of lhes Ilii :},;j '! �Qh SERVICES FILTER BED CI Distance to neanitW�yr11 "{ Foundation Property Line lilt SEEPAGE PITSI I Depth tilgi Ii ,IIIi� Number l' SUMPS Lt Distance to hearest: Weihll r'iI Foundation 1:Prooa* Line DISPOSAL PONDS 07] I hereby certify that I have prepared this application and 11Iit the work will be dons In accordance with,San Joaquin county ordinances,state liws, and rules and regulailoni of the Son Joaquin County r,'Il �-' i 4 ml ` ork ' Home owner or licensed agent'i signature certifies thiol following! "I certify that In the performance of the wfor which this perm ,it,s Issued, t shaft not employ any person in such manner as to become subja'at°tolworliman's compensation laws of Califorrns."CBntreciors hiring or sub-contracting signature certifies the following:"I certify that in the performanci'oi the work far which this permit Is issued, I shall employ persona subject to Workman's compensa- tion laws of al farnla." l ' The appiicsn m st ea11 for all req 'I s�t fti ompleto irawing on •reverse side. �rpit t � �, �,. I/ Signed ✓ ` � �,Ii�;. Title: C 1L� Date: ; sill. FOR!! DEPARTMENT USE ONLY I I-. it Data IL's l Arts t� Qa Application Accepted by _ . Z, Pit or Grout inspection byGita 11' ' Final Inspecelon by:L Oats Additional Comments. .'i I Applicant - Return till copies to: SantJoaqu a County Pubiic Heath Services . Snvirbnmedtal Health Permit/Services' ;� 40 HiSan{'Joaquin1 P 0 Box 20091 etkh OA 85201 �'�t hi' �r „� ✓ FEE /MOUNT DUE AMOUNTREall CASH RECt?IVEO[tY EI DATE PERM17'F10. INFO 1 J y4 .W 1. i.A iiasi [/� [M Tl.m l tv. ��l �, li k y r� 3�7/ :I]