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APPLICATION 93 '�9z� N SAN JOAQUIN COUNTY PUBLICrial��do: RVICAO ENVIRONMENTAL HEALTH445 N SAN JOAQUIN, PHONE (1 -3420_�� 7_ 141, 6. P O BOX 2009, STOCKTON,ECA 95201 PERMIT EXPIRES 1 YEAR FROM DATE IS J (Complete in Triplicate) r Application is hereby merle to San Joaquin County for a permit toconstrue t and/or SneIaPplichis Joaquin is Pude in ealthSanceSery withceo. San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation, of San Joaquin County Public Health Services. J YYOo �r9 eyePbD — ell Job Address '' (�.� City SSI^dot Size/Acreage o t Owner's Name ��,lWe ��/��('_r,�_ Address r _[3s f-JLr C 12y,- <' ( D C Phone �Y km Contractor �W ��f�C.f�iEe� SP/tl�y hd rdtd ass �License No. 6�-V"79 Phone TY OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION Cl Out of Service W ❑ I_, 94 p , PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitorl ell ❑ ISISTANCE T AR ST: SEPTI ANK S R LINES DISPOS PROP of aC O CATION r AGRIC ELL +7 R WELL �✓F'_ /SUMPS —�L ` INTENDED USE TYPE. ELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing U-Ciomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications— Il pecifications Il Public Ll Other Il Delta De ut Seal Type of Grout 6. 1 1 Irrigation _Approx. Do th Surface Seal Installe Repair Work Do ype of Pump H.P. State Work Done _ estruction ❑ Well Diameter Sealing Materiel i Depth r Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 11 [No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L Commercial_ Other Poe + e- Number of living units: 4— Number of bedrooms — Character of soil to a depth of 3 feet: Water table depth SEPTICTANK ❑ Type/Mfg 171-2217 'Capacily le- Or) No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well >y ate_ Foundation 1�_ property Line LEACHING LINE ❑ No. & Length of lines Total length/size t. FILTER BED ❑ Distance to nearest: Well --'I Foundation . Zg2 _ property Line X30 SEEPAGE PITS 11 Depth _ 25 Size _ Number c r SUMPS LI Distance to nearest: Well s�3fX7 Foundation Property Line aarlu� 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to become subject to workman's compensation laws or California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa. tion laws of California." The applica y:��}+at cell for all requl/` inspections. Complete drawing on reverse side. ) l+ Signed�KtA>i Title: �%1�6� 0-,ti Date: FOR DEPARTMENT USE ONLY Q' p Application Ac by / ^( f I Date Gua � r Grout Inspection by .� l Data 7 P tJJ��pp Final Inspection by Date 2.7 Addinal Comments: 71 Applicant - Return all copies to: San Joaquin County Public Health Services ii Environmental Health Permit/Services t. 1 445 N San Joaquin, P 0 Dox 2009, Stkn, CA 95201 Ar FEE AMOUNT DUE AMOUNT REMITTED RECEIVED SY INFO \ CASH GATE PERMIT NO. EM UpUrtEV.vnel /� /)-)/, // • -e) /� t�r/7 -7 ,) Err 14ae !!! .., [lt_/ (/C/ •/OS7 //iCI I%1