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jf APPLICATION AQUSAN +R COUNTY PUBLIC HEALTH VICES 445 N SAN ftlMNTAL HEALTH DIVISION P O BO QUIN, PHONE (209)468-3420 % 2009, STOCXTON P CA 95201 IT EXpIRES 1 YE Application 11 here (COMPIete i H DATE I UED by a �e in Triplicate) •DPlication ie merle in 8m Joaquin Count Joaquin county Publlc Health with Son Toe y for a Permit to construct s ""�� 3ervlcee. Quin County Ordinance No. 5kg ane 1862sannd ththe work e Rules herein described. This Job Address _/SG.5,4 jga vL and Regulntlone of San Owner', Name � City SIJi.,.l -bN_YNle�itlU Lot Size/Ac aN �Zq�o, Address /111 �� r•T Contractor J� ESNs/ 4A TYPELG� - �✓ff � 17 Address . 9 Phone 9 edTB; 3 OF WELL/PUMP: _IQCAyjspD,C. NEW WELL ----�_ License No�ICD PUMP INSTALLATION p WELL REPLACEMENT [� —�Phone 9/6 DISTANCE TO NEAREST: SEPTIC TANK SYSTEM DESTRUCTION 0 Out of SEWER LINES REPAIR L3Service Well FOUNDATION --� DISPOSALFLD' OTHER O Monitoring well INTENS AGRICULTURE WELL PROP. LINE TYPE OF WELL OTHER WELL 0 Industrial �� PROBLEM AREA CONSTRU PITS/SUMPS _ Open Bottom ❑ Man — CONSTRUCTION SPECIFICATIONS Cl Domestic/Private ❑ Gravel Pack Dia. Of Well Excavation S SPECIFICATIONS— I') Public Tracy t� Die. of Well Casing 2 C7 Other Type of Casing_ PVC- 1 1 Irrigation n Delta Approx. Depth �,.f Depth of Grout Seal G$/ SpecificationsoGut Repair Work Done U �wr eastern Surface Soul Installed b TYPO of Grout Well Destruction TYPe of Pump E� Well Diameter H.P. �--_. —�_ Sealing Material i Depth Stats Work Dona_ TYPE OF SEPTIC WORK: Depth—� Filler Material i NEW INSTALLATION I I REPAIR/ADDITION I I Depth Installation will ae DESTRUCTION I I fNo se ave: Residence ptic system permitted it Commercial_ Other available within 200 feat,) Public sewer is Number of living units: __ Number of bedrooms Oasaar �— of soil to s depth of 3 fest: SEPTIC TANK PKG. TREATMENTTie/Mfg PLTWater table depth .❑ Capacity -- --- No. Compartments Distance to nearest: Well FoundationMethod of Disposal ING LINE __� Property Line LEACH FILTERLEACH BED ❑ NO. 8 Length of lines 1-1 Distance to nearest: Well Total length/size SEEPAGE PITS Foundation Pro I I Depth PertY Line SUMP$ ----��Sire DISPOSALLl Distance to nearest: Well � Number PONDS O Foundation 1 hereby comity that I he —�'- Property Line rules and r Prepared thio application and that the work will be done in accordance with San Joaquin egulatiorp of the San Joaquin County Home owner or licensed agents signature certifies the following- tmploy any person in such county ordinances, state laws. mPlOY the followin manner as to become 9 "I certify that in the performance of the work ! r end In lawn of w: "I csrti Porto subject to workman's compensation laws of California."Contractor's which California.'• fY that in the mance of the work for which this permit is issued, I shall am to o whah this Permit is issued, I shall not I applicant m II for P Y Persons tub ec hiring Isub-contracting signature /yes yir�inspections. Complete1 t to workman's com ed (/ / � drawing on reverse side. pensa- Title: C. FOR D Date: - uion Accepted D ( �, FOR USE ONLY v r out Inspection by Date Q G Date Area `Comrrynta: Final Inspection by Dan (cant - Return all copies to: San Joaquin Count 1 Public Environmental HealthperraHealth Services 445 N San Joaquin, p 0 Box 2009, Stkn, CA 95208 it/Services 1 FEE INFO AMOUNT DUE AMOUNT REMITTED CK VS (20 �A�H RECEIVED BY DATE PERMIT NO. v g�.Do GG.-- `d UI ZVO W SR 00 ZI 74 �` 1