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APPLICATION FOR jD1 I1SR # SAN JOAQUIN COUNTY PUBLIC7�-SF$VICES ' J3� • ENVIRONYSNTAL HEALTHMU445 N SAN JOAQUIN, PHONE ,173420 P O BO$ 2009, STOCKTONT PERmiT E%pIREB T YEAR FROM 6A7llgVI&u= (Complete in Trlpllcatel Application le hereby mile to San Joaquin County for a permit to construct ead/or install the work herein described. This application to mile in ceamliaace with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County public Health Services, Job Address '95;CLi07 AO(• City 1-0479 rl!rVd Lot Stu/Acreage Owror'a Name _C WAYtJ Address 'ey, Phone Contractor '4Nrhe1V)e Address, 00R BGu Gtb"y/fLy. License NO. Phone s?3'Yzi f' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bonom ❑ Manteu Oa.. of Well Excavation_ Dia.of Well Calling {{}} Cl Domestic/Prrvns ❑ Gravel Pack ❑ Tracy Type of Casing__ Specilicad0ft Jt� I'I Public n Other n Dints Depth of Grout Seat Type of Grout d I i Inigalion —.Approx. Depth I I Eesstn Suriacs Saul Insisted by Repair Work Done ❑ Type of Pump H.P. State Work Done._ -� Wall Destruction ❑ Waft Diameter Sealing lsterial a Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIRIA0OITI9N I I DESTRUCTION I I (No septic system permitted if public sews.is • fl InsiNaavailable within 200 fest.) \_ noh will egged: esidenn_ Cornnarcial_ Other .-swy�.yC Number Of living Wks: / Number of bedrooms y Character of Hog to a depth of 3 ten: -S;A Water ism. depth '�O e SEPTIC TANK. 0 Type/Mfg I- Capacity 600 No. CIOMPMUm is PKG. TREATMENT PLT.C ' Method of Disposal_ Dinsnce to nearest: Wale_ Foundation /0' Property Line .Sd LEACHING LINE Qf No.d Length of line, 2 60' Torsi length/sire ,� r� FILTER BED ❑ Distance to nwrest: Wire ._ Foundation L.Sr _ Property Line ;C SEEPAGE PITS I I Depth _Sire -T' n /O' Number. 3 V SUMPS 0 Distance to rwnst: Walt/-j a Foundation /�� Property Line 'X If' DISPOSAL PONDS ❑ I hereby Cavity that I have prepared this Appication and that the work will be stone in#ccordance with San Jasquin county ordinances,state laws, and ruses and regulations of the San Jwquin County Homs owner a bcarsed agent's iignepm certifies he following: "I certify that in the perfamance of the work for which this perrnit is issued, I shag hot employ any person M Such manner as to bendrne subject to workman's compeneation laws of California.-Contractor's hiring or Sub-contracting signature Certifies the following: "I certify that in the pentormancs of the work for which this permit is issued, I shag employ persans subject to workman's compntw tion I""of Cart orNe." The applicant mur,j cap far aanJ'6gWred inspactiora. Complete drawing an revane side.- Signed ide`SignM X ./,ep dLtSNcZPsS� Title: Dale: {f,n)� FOR DEPARTMENT USE ONLY ik AppsWn AcCeptao by -7—al �22 Z2� � Date A-rea�/�v�1�-- .P or Grout Inspection by7-�r�L��% Date I/' Final Inspection by Additional Commnans: Applicant - Return all copies to: 8— Joaquin County Public Health Services Environmental Health Permlt/Services { Il 445 N San JOLQula, P O Box 2009, Stko, CA 5201 s +Flao ol3bs •+ `IrIte AMOUNT DUE AMOUNT REEMMII�TTED 7CACSH RECEIVED BY //jc APEflMl7y NO. . Ee r}h imiv.tines f` /� �_ ri� / �• `." V1�0 e u.2e I �