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i fix, APPLICATION FOR PERMIT � IIS j! 11 A ,. SAN AQUIN COUNTY PUBLIC SFALTH S DICES FN-VIRONMiNTAL HEALTH DIVISION P O BOX 2009 , STOCKTON, CA 95201 SES ,t -3447 (209) 46$ 1 0 jl R YEAR n 19gs `! (Compl:ete in Triplicate) pE�N II ski i��pp`�NTq Applicaytion le hereby made to San Joaquin County for &.permit to construct and/or install the work S ¢�abed. Thle application is made in cc=Pliance with San Joaquin County Ordinance No. 5E9 tend 1862 and the Rules and�R �a�`th(dna of San Joaquln:Ccunty Public Health Services. k Job Address _ 21-1 y e �`7YP. �T City -.` � , a,Q Lot Size/Acreage I Owner's Name V191 Address u j Conti actor 1' YJTI r rff�(uqAddress�71v 77� r' License No. d073-��i phonel oV�D/-DZ1I I TYPE OF'!WELL/PUMP: NEW WELL O WELL REPLACEMENT C_l I DESTRUCTION Out of Service 41e11 PUMP INSTALLATION C j SYSTEM REPAIR C7 OTHER p Monitoring Well [7 f � I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION "` AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS prG /9S7 I;o �,r n Industrial O Open Bottom C Minteca l Dia. of Well Excavation' Dia.''.of Well Casing A [/s4��A l4° U Oomesiic/Private ❑ Gravel Pack 7 T racy l Type of Casing II Specifications i `� Public ' I;] Other ❑ Delta Depth of Grout Seal 11 Type of Grout n v trriUaiion Approx. Depth ❑ 'Eastern I' Surface Saul Installvd by_ Repair Work Done U, Type of Pump 'k H.P. I State Work Done _ Well Destruction Well Diameter ,- Sealing Materiel Id Depth h!t4d G+arr�s t90 Depth 7 , { ----rT; b t 4 I,6 1�e� I TYPE OF SEPTIC WORK: NEW'1NSTALLATION 0 tAEPAIR/ADDITION Cf DESTRUCTION v (No septic system permitted if ptibic sewer is t available within 200 feet.) Instillation will saws: Residence _ mmerciat f� Other Number.0 living units: at of bedrooms d I,► Charactar of soil to a depth feet: Water table depth SEPTIC TANK Type/Mfg Capacity I No. Compartments PY,G. TREATMENT U 1 ' F Method of Disposal • ii Distance to n st: Well Foundation If Property Line a LEACHING:LINE Cl o. & Length of lines Toral length/size FILTER BED n Distance to nearest: Well I Foundation li Property Line "` 1<1 SEEPAGE PITS 1 I De Size I Nulmber u SUMPS I Distance to nearest: Well I! Foundation _ I� Property kine I'g DISPOSALiPOND5 O l 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 it Home owner or licensed agent's signature certifies the following: "I candy that in the performance of the work for which this permit is issued, I shelf not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perlormance of the work for which this permit is issued[ I shalt employ persons subject to workman's compensa- tion laws of California," !! k The applicant us[ all fo I squire ns ns. Complete drawing on re side. 3 Signed • Title: rlt.T Date: it " OR DEPARTMENT USE ONLY 1 7�hs-` ' 0 Application Accepted by Datil vV Area il �9 Pit or Groutfnspaction by Date Final Inspection by Date Additional Comments; Applicant '- Return s.11 copies to: SAN JOAgUIN COUNTY PUBLIC HEALTH 9EII ENVIRONMENTAL HRALTH,;DIVISION PERUIT/SERVICES 445 H SAN JOkQUIN, P .0 BOX 2000, STOCKTON; CA 85201 + i INFO AMOUNT DUE AMOUrJ�71 RfMtTTEO CK I j CAS H SH 1RECEIVEO 8y DATE PERMIT'NO. (H 13-24 111 Unsp ,N 34}a