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F.R APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC PLALTH SERVICES til &NVIRONV NTAL UEALTH DIVISION P O iOX 21709, STOCKTON, CA 95201 y; :'1 (209) 463-3447 2=11' EXPIRES YEi1X PROId 1?�i�E I,� 1� Gj (Complete in Trinlicate) Applleatlon 1a ereby axDa t� Qui❑ County for a ,xralt to construct and/or 'nst.Al2 the work herein described. This aPP1lcaUon is Bade in cco lianc, vIth San Joaquin Ccunty Ordinance No. 549 and 1862 and tho Rulos and Regulations of San Jca4uln County Pubilr He@–th Berrwlces, Job Address �_, y �-- --- City--s.�– Lot 9lteiacreage cjl� J1jJ^�'n� AdtlreaOwnsis NamePhone dd,es � NUs ��! � PYsone f. CCntratl3+ TYPE OF WELL;PUMP. NEW WELL 0 WELL REPL-ACEMENT [1 DESTRUCTION C Out of Sarvlce Well t_ PUMP INSTALLATION u SYSTEM REPAIR OTHER y1tso„�r1%Sne W�11 f may/ D'STANCE TO NEAREST SEPTIC TANK — SEWER LINES DISPOSAL FLD. PROP. LIN FOUNDATION _ AGRICULTURE WELL —__ OTHER WELL__PITS/SUMPS = I - INTENDED USE TYPE OF WELL PROQLEM AREA CONSTRUCTION SPEGrICAT10NS Ll Industrial O Open Bottom O Monfocs Du of Wall Exuyatwn Du.of Welt Casing U Oomestic/Prwate L1 Grevsl Pack U Tracy Type of Casing Spec.bcatans M Public f',Other ❑ Delta Depth of rm>ul Seal Tvon of Grout CJ lf,"t on —Approe. Depth ❑Eastern Surlice Seal Insured by AvoAit Work Done U Type of Pump H.P. State Work Dons_ ( Sealing Natorial a Depth Well Destruction 177 Well D4motsr – 1 � .•.: c:. Depth 7111er tsatarle.l L ILyth :• - •ryS. TYPE Of SEP?IC WORK: NEW INSTALU+T:ON O REPAIR/ADDITION❑ DESTRUCTION L (No saprc oystem permtted it pt+bt'o atwer is ayadable within 200 loot.) -.Ya "1• ? Insisti wlil serve: Rosidenca.�_ Commercial Other w: J Numbw of living unity,_ Number of bedroomr Charoctor of soil to a depth of]feet: Water table depth 1 SEPTIC TANK 0 Type/Mfg Capacity_ No.Coenpartfnants 4i• ,t1 4 PKG.TREATMENT PLT,0 Method of DsposN �oX res Oiatance to nearest. Wan Foundation_ Property Line �+ a LEACHING LINE 0 No. 6 Length of lines _._._ Total length/site s FIITEA BED %l Distance to nwsat: WeH_ Foundatbn Property floe �•.; SiEPAGE f1T5 11 Gepth Sire Nutnbsr I' SUMPS LI Distance to nsuest Well Foundation Property Elms i DISPOSAL PONDS O _ �i�•i[�;•;; t I hereby cartifv tail i hsps wopsfod this=ppitcanon end lhet Iiia work wi:l be done In accordance with San Joaquin county oidinanc#s,state Iowa,and - " ruits and roguistiona of the San Joaquin County Hcrne owner or licensed agent's signature cert:het IM fo!owiog: "I certify that In the periorman,e of the work for which this permit is issued,1 shall not emptay any Berson in such morner ae to become subject to workmen's compensation laws of Calilornu."Contractor's hiring or Wb-COnlraCting sIQM1Ura t , R S. + esm1fies the fogowing:"I certify t in the performance of the work for which this permit is iseued,I shall employ persons subject to wortmon's coTpansa• ... tion laws of It TIM sppliunt F •' eP I, .tions. C,ump7et*drawing r r a'ell t G`/ ~, Slgned x Date cL, PF 0 PAATMENT USE ON i' Applk atbr,Accepted by _ Data At" L ; Pit or Grtut IMpacthn by Dace�`� Final Inspection b� Data – ,�4,�'�'�` € Additional t:nmfnenn: _ '�� / �i'� /gk1 i�L.Ck=�rrr•� �++r�, I�Asrc�_ :,. Applicant lletum all copies tot 8AN JOAQUIN COUNTY PU LIC F.MTH SZRVICES ENV'IRONIIRNTAL HEALTH D1VISIOr PEHIIIT/88RYTCES ' 445 N 3AN JOAQUIN, P 0 BOX 2009, ETOCKTON, CA 98201 -�'. S FEE {,MOUNT DUE AMOUNT REM:T7ED CASH RECEIVED sY DATE PERMIT NO. j, INFO — -- .+ � T.15 t"�t I iXµ,'/OV��a} ��p�'/,i�-i'(.',+'+n�r.1'�.�.�Vrr_. ... � ,��ro•R'�JICY'��'YY�Pca.�k`[Z1i� l.^^y��$ff`�'��1 i." W9 �4 . :4 K4 r!. 1::1�-. 1+::'I4"r'✓fAh.'�•�llF.�Y-7tSk f!�r • if zo r