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'9 �k !r i.PPLICATION nn SAN JOAQUIN COUNTY PUBLIC IIEALt11 'NUI ENVIRONMENTAL ILEALTB DIVISIQA }� 445 N SAN JOAQUIN, PRONE (209)460,' P 0 BOX 2009, STOCKTON, CA; 9.52�1u PE IT EXPIRE13 1 YEAR FROM DATE tttt Cj�l�) (Complete j.n Triplicate.! .� Ayp/icatlon 1& hereby bade to Sa, Joaquin County rcr a permit to ec.netruct and/or install the work nereln described. This application Is made in compllan Te with San Joaquin County Ordinance No. 549 and 1862 and thr Ruies and Regulations or San Joaquin County Public HelthSeervijc�es�. Job Address _ 1alp,%-.-------_ C", Lot> / Lot Size/Acreage Owner's Name /�Lc-J1.�L4�'t(t/tial �_�l..�_��.cC..�-[ Phone Conloclor- r J . /i//L n __Address jP,0,i._//-C j,7"22wop—License No. /_7 Phone TYPE OF WELL/PUMP NEW WELL :l WELL REPLACEMENT rl DESTRUCTION Ll Out or Service Well Q PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP LINE —_ FOUNDATION AGRICULTURE WELL OTHER WELT.__. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rl Indusloal G Open Bottom Cr Mant.,ca Dia of Well Excavation Dia. of Well Casing ,i r l Domssuc/Pnvate Ct Gravel Pack* !l Tracy Type of Casing. _...-..__ Specifications Cl Publ,c I 1 Other f I Delta Depth Of Grout Seal Type of Grout 11 ImBatton ^_Aplwox. Depth I I Eastern Surface Seul lnstaited by i Repair Work Done U Type of Pump H.P. _ State Work Done Well Dettruction O Well Diameter Sealing Material L Depth --r Depth Tiller Material a Depth TYPE OF SEPTIC WORK. NEW INSTALLATION ' i HFPAIRrADDITION DESTRUCi:JN I I (No septic system pormrtted If public tower is !// available within 200 foot.) ' Installation will serve: Residence! Commercial Other Number of living units:_rL Number of bedrooms t Characrer of soil to a depth of J feet: T— Water tabl,depth_ Ile SEPTIC TANK C Type/Mfg yi( __ IZZ Capacity � ie No. Compannrnis _ PKG. TREATMENT PLT.❑ , Mashed of Disposal Distance to nearest. Well Z Foundation 1�I _ Property Line LEACHING LINE No.8 Length of lines Total lertg;hhixe_ 1�r7 T FILTER BED C) Distance to nearest-. Well 0 Founaabon i 2 Property line .1 SEEPAGE PITS 11 Depth 0 /L S. Number r_ SUMPS � Distance to nearsat: Well IZMt Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prspa•ed this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and rules and regulations or the "San Joaquin County Horne owner or licensed agent's signature certifies the following: "I ceRify that In the performance of the work for which this perm)is issued.I shLll not employ P Y an v person in such manner as to Docome wDject;o workman's compensation laws of Cdilnrnia."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.I&lull employ persons subject to workman's compenM. tion laws of California." The applicant must till fo vl r us_edjinlysy�pections. Complato drawing on reverse side. w, ) �7r a► Signed X 1_';;P1 i�.� "'�I`^-- Title: �C>Z•.��f/ic Date: l/_� FOR DEPARTMENT USE ONLY 1 4 Application Accepted by —" ' Date Aroma • .�,,/� Pit or Grout Inspection of Date Find In&pection }_ (last J;C?/ Additional Comments: Appltcn.:: - Return all copies to: San Joaquin County Public Health Services Environa,ent,:l Health Permit/Services 445 N San .tosqutn, P O Boa 2009, Stkn, CA 015201 FEE AMOUNT DUE AMOUNT AEMITTED �(` H RFC[IVEO BY DATE FERMI/TNO. Ir4Fis 11.74 IREr.,r+s,1 i