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APPLICATAM FOR PERMIT SAN :)AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE., PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PiLftJLU.—UCP-U-Ek--t')._)r.E61LEIWALPAIK1CaUM. (Complete in Triplicate) Application is mireby made to Sari Joaqu,n County for • permit to conritruct itni/or install the work here:t described. This application is assde in cnegliance vith San Jcaquin County Ordinance 5.- 514 and 1E62 and the Rules and Regulation. of San Joaquin County atilic health Services. _41 Cy ..7T P-41_- - ..iob Address _ _ ___:--' .___ Lot SUP/Acreage Chyner's Nene _11.1 i Address „.0... ContraCtOI tia_i Ail./..s 11__Lin_ci_in N ili-yv, Aidress •55:-.3__ TYPE OF wELLipumr WELL PEPLACEVENT ' . r::sTRucTioN ,_ t of Service idell C.1 ------------ tacint tcring Well L-1 NEW WELL : PUMP INSTALLATION ....:. SYSTEM REPAIR ;.' OTHER C: DISTANCE TO NEAREST SEPTIC TANK SEWER LINES ._ — DISPOSAL FLO PROP LINE _ FOUNDATION .... — AGRICULTURE WELL OTHEri WELL PITS,S..,M - INTENDED USE TYPE OF WELL PROM FM AREA CONSTRUCTION EPiCIFICATIONS 1 I Industrial 0 Open Bottom \ ?IPTA:ancyteca Dia of WO Escavanon / ' I Dia of Well Lasing i r ! ' Domestic/Private LI Gravel Pack T‘pe of Castro .. . _.../.... _ , .,pecificat•ons I . NMI': I Other , ' Delta .12......... Type of Grax_Cal.i. t2c E k c- O.ern of Gm t SPaI _ 1 , Initiation , _ Apples Depth I . Eastern t tiller' Seel l'ttse.Jd nv Repair L'il•lik Done i 3 Type of Pump H P __;__ .._ _,__' __ State Work Done _- Well Destruction n Well Diameter .....,,k, Sealing Piet, erial & Depth Depth 1,3-S ' _ _ Tiller 4st erial I Depth TYPE OF SEPTIC WORK NEW INSTAI LATiON i 1 REPtisti ADD TiuN . DESTRUCTION r %(10 Installation will serve Residence _ Commercial __.\ Oyir Number of living units — Number of bechbors _ 1/4.. t) 'Malachi,' of soil to a depth of 3 feet — / .k.' Water table depth SEPTIC TANK 0 Type/Mfg -- Cacity No. Conspartments Method of OrlOnsal PKG. TREATME,T PIT I) _ Foundation — Property Lose Distance to near . . _ LEACHING LINE LI No. \LeS of tines Total iengthrsize FILTER BEU Dist5r.4e,,4o learest Well __ Fount:anon Property Line — SEEPAGE PITS SUMPS .c IN —_ _ Number N Depth _ I I Di kr stance to Nearest Well _ —__ und n atio _ S-1. _...— —_ —_ Property Line -- I hereby certify that I tithe •epared/this appl d ication and that the won *ii'be dune in sciornanze with San Joaquin county ordinances. State laws. and DISPOSAL PONDS ( I ; \z,s4 n Jd HOMO owner or licensed agentisignature comities the knowing "I certify that in the performance of the work for winch this permit is issued. I shall not rules and regulations cf the 'aquin county employ any person in such ma:Iner as to become subiect to workman I compensation Laws of California - Contractor's hiring or sub.contracting signature certifies the following - I certify that il the porton/lance of the wonk for wisith this permit is issued, I shall employ persons subiect to workmen's compensa- tion laws of California." The applicant must call for all diftuired inspections Complete drawmglnaerse side I SignedX_ILIA.,:f • 12-'2--- ---___ Tide L. 2.714T„...L_______ — Date: Fil...DEPARTM2NT USE ONLY Application Accepted by__c_i_.\...A.sts.—lki,Z..._, .k:D. Isrii-ri;•••V ,-.-wzr--- —. Date Pit or Grout Inspection by Date _ Final InspeClion by Additional Comments. . \ Applicant - Return all copies to: INct septw SvSlom perm,u,,1 ii ptibkc SerNel is available within MO feel I Area — 1-- -Oat. — .k1 Joaquin County Public Health Services, Environmental Health PermitiTervices 1601 E. ResPiton Ave • P 0 Box 20C9, Stockton, CA 95201 FITT—AMOUN? ONE INTO am0;is, nEktiTTE-CF-T CASH .K I /ass In IT 24 ts