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APPLIICATION SAN JOAQUIN COUNTY PUBLIC AEA aEyf SERVICES ENVIRONMENTAL HEALTH I3I_VIS S r S 445 N SAN JOAQUIN, PHONE —, 8 3420 P O BOX 2009, STOCKTON, C 9 Cn PERMIT EXPIRES 1YEARPROXII (Complete in Triplicate) Application 1a hereby meds to Sm Joaquin County for a permit to construct and/or install the York herein described. This application is made in conplience with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joe4uin County Public Health Services. Job Address 'n1� Cn r Lot Size/Acreage Ovmeri Name VY Address /VL1 ' Cdnlracfa VaLL Addiesi 7U� License Nb. �,2_;C_L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑I SY TEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK _ EWER LI DISPOSAL FLD. PROP. LINE FOUNDATION GRIC URE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRDBL PEA CONSTRUCTION SPECIFICATIONS 9 Industrial ❑ Open Bottom ❑ 1 ca pre. of Well Excavation. Dia. of Won Casing Cl Domestic/Private Cl Gravel Pack Trac Type of Casing__ Specifications I'I Public I:1 Other I� Deh9 Depth of Grout Seal Type of Grout I I lmigallon __ Appros. O m I I Easier Surface Saul Insralied by Repair Work Done Ll Type of Pump .P. _-- State Work Done _ Well Destruction ❑ Well Diameter ling Naterlal a Depth w, Depth Filler Material a Depth 11J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION IV DESTRUCTION i I INo septic system permitted if public sewer is 4) available within 200 INtJ rv. Installstwn will arta: Residence_ Commercial— Olf Number of living units: . Number of bedrlw ! Character of ads to a depth of 3 foal: . 011 / Wafer fable depth SEPTIC TANK ❑ Type/Mfg. Cape tcf y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to merest: WII - Foundation Property Lina LEACHING LINE Cl No. 8 Length of lines' ,., i I langah/sireVal FILTER 8E0 ❑ Distanceto nearest: Wetl Founcation _ l¢_ ,1 Property Lina SEEPAGE PITS 1 Depth Si+e Number SUMPS Ll Distance to rat: Weer' Foundation . Property Line DISPOSAL PONDS O I hereby eenity that I have prepared Ibis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and , rules and ragOaliono of the San Joaquin County - a Home owner or licensed agents oigrremre onifiss the following; "I certify that in the performance of the work for which this permit is issued. I shall nor employ any pawn in such manner as to become subject to workman's compensation laws of California."Contractor'&hiring or sub-contracting signature wrtlfies the following: "I certify that in the performance of the work for which this permit is issued,I shell employ persons subject to workman i compensa tion law&of California." The appkcenttmm/i+{YcaN foaquked inspections. Complete drawing on reverse side, Signed x ULM'l {]i L, Title: ce--47°L.� Data: . FOR DEPARTMENT USE ONLY Application Accepted by �.,Q.e.� -' '� - Date G Area Z) Pit. . Grout Inspection by Data Final VupeoWn b; tZ er-% ' Date 1� 92 Add//itional Comments: Applicant - Return all copies to; Ban Joaquin County Public Health Services z�1 44nntel Health Permit/Services 4San fn K a455 N N SaBan Joaquin, Box 2009, Stkn, CA95 O1 IMF& AMOUNT DUE AMOUNT REMITTED RECEIVED BY P CH 1}24$AEV.I/.Sl I I lJ[/ / f —r' S g lap,qV 2 EH 1441