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,f Max f ° J APPLICATION „ o4 SAN JOAQUIN COUNTY PUBLIC HEALTH "t7R I ENVIRONMENTAL HEALTH DIVISI 1io# ' 445 N SAN JOAQUINr PHONE (Z09)46 �'• �i P O BOX 2009, STOCKTON, CA 95` �1AC u PERMIT IH 3 1 TE TSS tt O� (Complete in Triplicate) ' 1 . Application is hereby arde t0-Sap Joaquin County for n perait to construct and/or Smtall the work herein described. This spP11Catloo 1s Made in CcWll►nce with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations or San Joaquin County Public Health Services. Q� p f� y� Joh Address c2 tZoo .-s 6+EF'r� L>b City F Wt Size/Acreage 4114-A151 , i f Owners Name Anldress a� 7��-J'/'1 /f Phone y � ca,vatw-41a Address - icense N%2aig5a; Prom TYPE OF VKWPUMP, NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION 0 Out of Service well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring well O i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i t' FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIPoC3APONS CI bukawisl •� D Open Bottom "'R O Mer+1eu Die. of Wall Excavation - — Dia, of WeN Casing Cl Dohnsa /Purists; ''W'O Gravy Pact 0 Tracy I . Typeiof Casing__ 5S vttorw _ 0 1 it P"bet fl other f1 De1ta Depth of Grout Seal 9" N� I k"Ital,on _Approx. Depth I I Eastern Surface Seal Instabad Ayw!A 1Vra8 Repair Work Done 0v Tips of Pump H.P. Sista Wort Done _ 1 777 WON Osstruct on O -WeN Ownetw Healing Material k Depth c �1 -Depth Pillnrz Iwtarlal A Depth �,.Ai lOAQI IIN COUNTY v, TYPE OF SEPTIC WORK: NEW WSTALtATION I-I REPAIRIA'DOITION DESTRUCTION I I INo sspac ,� �Instaaition vA s-arva' .- Number of fiwwig units:, .Nutrbw of bedrooms Character of wif to•depth of 3 Net.. LI,Aca Water table depth 1 SEPTIC TANK. . i 0, Type/Mfg - _ Capacity ` No. Compartmmn PKG. TREATMENT PLT. ❑ ..� ` ' r Method of Deposai f t Distance to smest: WON Foindwion Property Lim LEACHING LINE hip. 6 Length of ams — A-50 1'1 Total length/sire FILTER HED ..-fl Distance to newest:- 4TOM � _42*1"RpurwNdpn Prop" Lim SEEPAGE PITS 1 1 Depth` Sire Number * . SUMPS LI Distance to"naeraw: Wali Foundation Property Lim er DISPOSAL PONOS O I hereby certify that i have prepared tiffs apptcatipn and that the work will be dam in accordance with San J rules and rsgt4avons of the"San Joaquin County Joaquin county ordinances. state Iowaiattd Hans owner or ktaRrssd agerrt's signature c rtiIiis,dee fokowmg: "1 ertity ine that in the P'd0fnce o!It's work for which this permit is issued,i.ahso hot employ any PIRWA in aueh mannan as to become wbjsct to woArnsn's compensation Iowa of Caliiomis."Comranors hiring or su4caWae!ing signature certifies the folwoinq:"I rardW that in the perfamerws of the work for which this permit is issued.I SW wnpwy persona subject to workrnaru'M conpama- ' tion lista of CNiforrrh."; ' The appkcarw must CSN far no Unused inspections. Compfale draw:.ng a:.ravine was...� /f ,s SpnaO K li/ � _�Title: Dow.';Data: LS- 77 9S/ DEPARTMENT USE ONLY APOGation Accepted by - • I y DataJ Z. �Aras ` I112 Pit or Grout Impsebal by ' - Date .. . ,Fuer Vapacaa+by-� A1G..I iI.-) - Dam.'T. Additional CtNrarants: Si--s a&Mdfa f rvr 040 . Applicant - Return all copies to: San Joaquin County Public Health Services Eavlronsental Health Perait/Services - j,\� "t 445 N San Joaquin, P O How 2009, Stts, GA.95201 L I FEE AAIOl1NT OUE r AAgI/NT REMRTEO H RECEIVED gi f1t7EI INFO ►ERsstT'1Mp, . . frr uH taEv.rr+sr f-",: 1 r DID r,