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APPLICr I FOR PERMIT SAN • ,QUIN COUNTY PUBLIC HEALTH S 'ICES ENVIRONMENTAL HEALTH DIVISIdIr/ P O BOX 2008 STOCKTON, CA 95201 (los) 468-3447 APR 2 9 1992 (Complete is Triplicate) �Ty Application is hereby ride to San Joaquin County for a permit to construct and/or inatall the mor "'This ayplication ie cede in cimVii"ce with San Joaquin County Ordinance No. 549 and 1862 told the Rules t e+ Joaquin Couty Public Health Services. Job Address 119 &5-t eralrY 12 City_tml Lot aisle/Acrea4a 50f ACyP�S I/V�5 -li .jAddress �i U �yo�v BwQZ�x) Phone 5 O Owrar'$None &C' n X,: T , IVvn + rtirwa �Contractor__ 0 rasa e d, 531-98 Phone 37 TYPE f WELL/PUMP: NEW WELL O WELL REPLACEMENT C? DESTRUCTION O Out of Service well 0 P P INSTALLATIION0 SYSTEM REPAIR O OT lbttitorind well X DISTANCE TO NEAREST: ?TIC TANK SEWER LINES ��T DISPOSAL FL::d/L, PROP. LINE �1GUft� F NDATION Fr v AGRICULTURE WELL fJ/A/A" OTHER WELL PITS/SUMPS N A INTENDED U YPE ELS. PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1,_1 Indultrial some Mentoca Dia. of Well Excavation_ / , y Dia. of Walt Casing A Domestic/Private Gravel P Trac Type of Casing, .!/ 3" f :t2 - Specifications.....•..-. 0 Public Cl Other Delta Depth of Grout Seal !!J� CAJEE Typo of Grout r CJ trrivatlort Approx. Depth Eastern ace Soul Installed by Y ."� Repair Work Done G' Typo of Pump N H.P. State Work D GP&A- u�-1-i Ate �tr Wed 0ottruction 0 WON Diameter b ` Sealing V4teria1 d Depth .r Morlo,_� /tv,3-r Ai- y .� f�j Piller Kitorial b Depth A/,�/ vvf�4'' �, Depth - - EL=- OF SEPTIC WORK, NEW INSTALLATION M REPAIR/ADOITION CI DESTRUCTION M (No seplic system permitted it pontic rower is available within 200 foot,) (� InfItgobtion will so"! Residence— Commercial_ Other Number of living units: Nu r of bedrooms Ch.crevof of sod to a depth of Water table d3pth SEPTIC TANK A /Mfg --� Capacity _.'____._. No. Compartmdnto PKG, TREATMENT PLT. 0 Method of Dltpoaal Distance to Well Foundation — Property Lino Z7 LEACHING LINE 0 No. A Length of lines Total length/sizo FILTER QED n Distance to nearest: u�cion• Property Lino SEEPAGE PITS It Depth Sire `�^ Number SUMPS Ll Distance to nearest: Weif F ndati Property Lino DISPOSAL PONDS O I horgby comity that I have prepared third application and that the work will be done i ordo ee with Son Joaquin county ordinances, $tato laws, and (vies end regulations of the Son Joagvin County Homo owner at licensed agent's signature canifbs the following: "hcemify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workm s compensation laws of California,"Contractor's hiring of sub contracting aignatvfe `I certifies the following: "I comity that in the porlofinencs of the wo(k)pr which this pelt Is issued, I shall employ parsons subject to workman's compensa- don taw$of Ceufornla." ///fit The applicen st c N for ON ee ed nspectionty,-�ompletp d[I}+ivIng on reverse side i' t (� Signod �r ,f Title: flyue m, t%Jfi4m f1L`l 51 Data, FOR DEPARTMENT USE ONLY Application Accepted by Dato Arco IV36 S- Pit or Grout Inspection by Date �•�-� -•�-� D�t�_._._,_� final Inspection by Additional Comments: - Applicattt Return ell copies tot SAN JOAQUIN CbUNTY PUe�CHMEALTH SERVICESP.NVIROnOTAL HEALTH DPREMIT/SERVICES440 N SAN JOAQUIN. P 0000, STOCKTON, CA 95201 IPit NFO AMOUNT DUE AMOUNT MkMiTWO ASH RECEIVED By DATI PERMIT'NO. IN 0•74 1aIV.1/4%) �- �� EN 14.13 I •d vt :o aE,/zo/zo woa:i