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ti -.04 APPLICAIION FOR PLAW IT 1 SAN JOAQUIN COUNTY PUBI.:C ILEALT11 SERVICES ENVIRONYENT41, 11iiALTH DIVISION .1601 E. IIAZFLTON AVF-- , PRONE (209)468-3420 P O BOX 2009,. STOCRTON, CA 95201 PIiRYI1' EXPIRiiS 1 ?:IAR F'RQIL DATE ISSUER (Complete in Triplicate) Application Is hereby made to San Joaquin County for a perm-.* to eenstrc.c'L an.'/er inctall tae vork herein dtscrlbed. This _ application is wade In compliance with ban Joaquin county Ortmance go. 544 and :.862 and the Rues and Regulations of San Joaquin County Public Health Services. �• 1 \i 1 \ Lot 5111.Aererige ✓ Job Address / r -if��t'� C.n _ (�. �) ,I F / � 1j1 (' � Phone `CJ Ownar's Name/' i�S_11(c {`- AAdress Contractor ( � _.G!�s L /)�^"7 '---'r[� l-cerse Nci r`/ �-�� Poo •�,'� Address. .c a...�.__.. „G._..._ c.'21 _ -•.'- �rTt�• ,x-_ - TYPE OF WELLIPUMP.} NEW WELL �. WELL REPLACErAENT i t OESTRUCTIOR C Out of Service Well _ lbnttorina [) PUMP INSTALLATION SY'iTEr,;REPAIR OTHER G SEWER LINES DISPOSAL FLO _ PROP. LINE DISTANCE TO NEAREST: SEPTIC TANY. __ -- -- FOUNDATION_,- AGRICULTURE ___ OTHER V✓ELL---- PITS/Str�aP S ._ tNTENDEU USE TYPE OF WELL PROBI EM AREA COYSTRUCTION SPECIFICATIONS D.a. of Well t:ating _ (1 Inuustral -� Cl Open Bottom C'7 Man.leca _ Dia of Well Excavation ( Oomeatic/Pnvate I_l Grswr Pack Tracy Ty'rs of Casing-__ — Sperctficallons Other Delta D.pm of Grout Seal .-- __ Trlae of Grtsu. -= Il Public Other �) I I longation - Apra. Depth I I Eastern Surface Seal Insubad by, Repair Work Done L Type of Pump H P. Stats Vwo,k Dona - y Well Dlarneter Sealir-d Material f Depth -1/ Wall Destruction ❑ -- Depth _ }'Siler `Mterlal a Depth TYPE OF SEPTIC WORK: NEW INSTALLATr"1NJ,4 RF•'AIRIAOG17101`1, . DESTRUCTION i (Nm -,thin?00 feet1.111 .) d;wuk:ower,s Installation will serve' Residence_lam Comme'!Iao-3__ / �- �1 Number of bwmg units: __!_ / � -1 � _ _ _ ,Water table depth Z- Character of 60'1 to a depth of 3 feet:_ ��) , ��_R ( � _ -.-J--�- No.Cam�ertmenq ..6� SEP?IC TANK D Type/MfgJ ams Capacity- Mstr.od of Disposal PKG.TREATMENT PLT.O Distance to nearest: Well Foundation __.-_ Properly Line - --'- —Total ten thisue�1' LEACHING LING t No. 8 Length of Imes ,,,:_i�L-`-��----------•- b �' FILTER BED I I Distance to nearest: Well Foundation_______ Provany Line ^� SEEPAGE PITSail Devth .2 Sue _. L: _�_. Number ' SUMPSt.1 Drs\snce to nearest: Wei Foundation-______- Property:ins DISPOSAL PONDS I 1 hereby randy that t have PrePAred this svt'I'catwn and the:ins woo1 will be zona a,ecio.IL"Ce wan San Joaquin county ordinances s'+ro lavys,4ndeZ rules and regulations of the San JOagUIn Countyv whnp,Ih-S pernvt is IsJuod•I mall r.-.t Home ownal or f Cansed agent's signature yortdtdi the following -'I corlAy that m the perl0rrn ince rme wt employ any parson in such t, nner as to becomsublect to wokrn tan's compeesatfon llws of Ca'iloroa l.ontrector-s hitting or wtreen•racn.\g slgnatu' ue Carllfies the following:'"I candy that In the performance of the work tar winch this p►imt Is LL1Jed,i shall employ psrsens suApci to work ion's COmf it VP tion Isws of California." . The applicant must cell for all required"Pscuor Cc-plots drawmp on reverse side. C- Spn �.n��-��-__ Tnb: �.t r�i�L_ Dale: -- �- JI R DEPARTMENT USE ONL'[ Oa.e Area ' — pplication Accepted by -� rI , orrGInspection by -"'� Date -1 -Final Inspection by(-�ddkionrol Com.atsntc �- Applicant - Return all copies to: San Joaquin County Public Health V Services, Fnvironmentil Rvalth Persalt/Services 1601 E. Haselton Ave_ P 0 box 2009 Stockton, CA 95201 FE AMOUNT DUE AMOUNT REMITTED x RECEIVED 6Y DATE PEnMIT NO �I \ G fF-8-1 ASIi ��rw ti is IA[V.1:e sI� / // .i7D � �� [R s•la l�-_L-r