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APPLICATION ?r$ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ; 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 i PERMIT EaIRES 1 YEAR FROM DATE ISSULD (Complete in Triplicate) t ApPllcatieO is hereby made.to Su Joaquin County for a Permit to construct and/or install the v ea and ° herein described. Bans J application is made it compliam a with Ban Joaquin County Ordinance No. 549 and 1862 and ilia 9 Joaquin County Publlc Health Services. Job Addie t _ LAC11y pin AlrEcA Lot Size/Acreage //O .Y -74-7) Ail,_ .: Owner's Nama JCA LFtJ MEVE ' Address 3 70 Al IS91-J ST �rJAAlTr PhcM �2 59– 7 a C"I'actor�L4�� E <<1- 5J Address 7 led.AD AT _License Na.��?sem_Phone 7� (YPE OF WELL/PUMP: NCW WELL ❑ WELL REPLACEMENT t1 DESTRUCTION ❑ Out of Service wall PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Voll O DISTANCE TO NEAREST: SEPTIC TANK _ S'><WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AG CULTURE W OTHER WELL PIT"/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR NSTRUCTION SPECIFICATION$ ❑Industrial O Open Bottom ❑Manteca Dia.of Well Excavation Dia. of Wall Casing 171 Domestic/Prvate ❑Gravel Pacx ❑Tracy Yte of Casing_ Spocdkations I'I Public I"Other (1 Delt th of Grout Seal Type of Gran I I Irrigation —Approx. Der•th I I tem Surf a Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well De*!rvction O Well Diameter Sealing Maters i Depth Depth Tiller Material a Depth_ i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION DESTRUCTION I I lNo septic shin system Dor200 t11ed it aibhc sewer is avaI Installation will sores: Residence'_ Commercial_ Other 1 Nsmber of IMng units:._ Number of bedrooms Character of*OA to a depth of 3 set: S•. !Alb Y Water tsbie depth t SEPTIC TANK O Typw/Mill Capacity No.ComWrtmenta i PKG.TREATMENT PLT.❑ Method of Disposal r Distance to nearest: Well Founristion Property Line i LEACHING UNE leo.b Length of lines SKr 'QTotal length/size FIL 7 tR BED ❑ Distance to nearest: Well �O, Foundation_f[ Property Line 8 ' j ! r _ t '•�- SEEPAGE PITS it Depth Sits Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I ,at,unity that I have prepared this application and that the workµill be done in accordance with San Joaquin county Ordinance*,state iasis,and rules and regulations of the San Joaquin County Hmis ownar o licensed agent's signature certifies the`oliowing:"I cenlfy that in the performance of the work fa which this Permit tr traced,1 ignH nos anytoy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature unities the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons aubloct to workman's eorttpensa- Zion tows of California." The applicant must call for all required inspections. omplete drawing on reverse side. r Signed L Title: &"ZL- Date: "x'92 FO i ONLY _ ;r Application Accepted b Data `s A Pit or Grout Inspection by Date Final Inspection b Datrt� t� i S Additional Commence: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services CA 95201 445 N San Joaquin, P O Box 2009, L17 K RECEIVED DY DATE PEPIMIT'NO. AMOUNT DUE AMOUNT REMITTED CASH . FH ti it IAN.Irel� / •� S �CC� w las