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APPLICATION. FGR PERMIT SAN .TOAQUIN COUNTY PUBLIC HEALTH SERVICES ± EN V I RONMEN'T AL IiEALTH DIVISION I V I S I O 01 p O BOX 2009, STOCKTON, (209) 468-3447 Y R (Complete in Triplicate) 4�2 SS-27v-p�1 t to construct and/or 62 andltheevork Rules and Regulations of Sanin described. a Application is hereby made�to San Joaquin County for a perms � Mance with Sari Joaquin County Ordinance No. 51►9 and 1862 and application is made in cotrtp * Lot Size/Acreage �, 00o gc+tPs Joaquin County Public Health 9f rvices. �� prmS//ilc'W 3e/u5 I Q City S 5 r f job Address a 3 900 1/0/�� ;�r/vs? a09'e36-l� [ / � phone Address 7roe l Owner's Name S3 5 /.tdvSitrr'a AVS S/8//. 99 Phone Cffa'+m #f4.L t of t 3aSP License No. E>r � Jf!'G+ PvvrCP Address DESTRUCTfON ❑ Out of service well ❑ Contractor WELL REPLACEMENT ❑ Monitoring t NEW WELL GY OTHER O l TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION 0 DISPOSAL FLD,.�--- SEWER LINES ------~ OTHER WELL�—� PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK .�—�---�—� AGRICULTURE WELL ------ � I �e mo FOUNDATION — 1< PROBLEM g1�EA CONSTRUCTION SPECIFICATIONS e/ INTENDED USE TYPE OF WELL Dia. of Well Casing LJ Dia. of Wall Excavation r G� industrial ❑ Open Bottom 51-A SID P/C- Spec ifications ��/ (Tracy Type of Casing Type of Grout l�tic -f Ll Domestic/Private C�t'Gravel Pack t (uy r l;l Otter 0 Delta Depth of Grout Seal Ar t ❑ Public Surface Seal Installed by C € Ci Irrigation ,2O.Approx, Depth D Eastern State Work Done ` H.P. Repair Work Done U Tyle of Pump Seal" Material f, Depth Well Destruction ❑ Well Diameter Filler Material i Depth Depth TYPE OF SEPTIC WORK; NEW INSTALLATION J] REPAIRlADDlTION Irl DESTRUCTION'Cl available within 200 feet.) gd d public sewer 1s I lVIO I Installation will serve: Residence Commercial Other — Number of living units: Number of bedrooms Water table depth i Character of soil to a depth of 3 feet: Capacity__._._-..--- No. Compartments SEPTIC TANK: thod of Disposal PKG. TREATMENT PLT. Ci - 1- property Line I Distance to no Well — Foundation_______�� Total length/size LEACHING LINE ❑ No. & Length o! lines Foundation Property Lina I FILTER BED n Distance to nearest. Well 1Siie { SEEPAGE PITS 11 Depth NumberProperty Line SUMPS Ll Distance to nearest: Well Foundation i DISPOSAL PONDS ❑ ` 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 f l not rules and regulalions of the San Joaquin County work for Home owner or licensed agent's signaturebecoies the me s subjecpto warkman'sowing: -I rtcoythat in the mpenaation iawaool California." Contractor'sthiri 9t orpsub-cont ce nglsignlaturre k employ any person in such manner as to rsons subject to workman's compensa certifies the following: "!certify that in the performance o!the work for which this permit is issued, !shall employ p4 t tion taws of California." The applicant Ty st call for all reci in flans: Complete drawing W. reverse rsiP� /��iS7R � �75 i K Date: Signed Title: - — FOR DEPARTMENT USE ONLY � ` Date H_.7 Area Z e 6 Application Accepted byia 7�F I' Pit o Grou inspection by Date ® Fina! Inspection by �— Date�.---,�-- Additional Comments: i ;-Applicant - Return all copies to: ERVICES NNVVIRONMENTALJOAQUIN O HEPUBLIC HEALTH DIVISIONPERMIT /SERVICES I 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 CK RECEIVED BY ;ATE PEFIMlT NO. r FEE AMOUNT DUE AMOUNT REMITTED CASH INFO 1 5/ o a- . EH 13-74 IREV.t/N 5) ,rm EM 147e