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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � + ENVIRONMENTAL HEALTH DIVISION � ' ��' P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 " , � R ?RQx_PA= •d ltd (Complete in Triplicate) SAI`:10,gow!,v couN r T) Application is hereby made to San Joaquin Count for l 1•`` :,� 1�}» 9 Y permit to construct and/or inatalll This application is grade in caatvliance vith San J + ani i s Joaquin County Ordinance No. 54g an 1862 and the Rules and c Joaqula County Public Health Services.� \� -:0Job Address SEE 1�`��/ City"ON Lot gaze/Acreage UNKNOWN SANTA FE PACIFIC 88$ SOUTH FIGUEROA STREET Owner's Name PIPELINES Address I DS ANGE"I L,.0 9nn17 Phone (916)62 -2431 F - 212 PILOT AVE Contractor _MONIS f1Ril L.INI;�O.. Address License Nota 951 C57_•_Phone Jang)igg-9139 TYPE OF WELL/PUMP: NEW WELL ( RX WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER 0 Monitoring Well i7 -DISTANCE TO;NEAREST: SEPTIC TANKF-IINKNOWN SEWER LINES U KRQWN�— DISPOSAL FLD. --- PROP:--LINE 4 FOUNDATION!I KN M AGRICULTURE WELL IfNKNfMW&HER WELL - PITS/SUMPS = V I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ lnduarisl 0 Open Bottom O Manteca Dia. of Well Excavation n loll ..._ Dia, of Well Casing tjd Domestic/Private D Gravel Pack r 0 Tracy Type of Casing Specifications C'3 Public qqih ❑ Deita Depth of Grout Sea1617 7!ra -4 TYpe of Grout�! Irrigation CATHO�I[;AVggs7FD��t�ON❑ Easter , Surface Seal Installed bye PlImp S1 IIPDV17F)_ Repair Work Done U Type of Pump H.P, State Work-Done_ Well Destruction 0 Well Diameter r 10" Sealing ftterial i Depth 55 Depth I �+ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION CT DESTRUCTION 0 INo septic system permitted if public sewer is available within 200 feet.] J Installation will-serve: Residence Commerciale, Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: i ter table depth SEPTIC TANK 0 Type/Mfg Capacity Water =possl on ProperCompartments PKG. TREATMENT PLT. 0 _ Method of rt Distance to nearest: Well Foundatity Line LEACHING LINE ❑ No. 8 Lengthtof lines - Torallength/si:e FILTER BED l-1 Distance to nearest: Well Foundation Property Line SEEPAGE,PITS 11 Depth Sire Number � -�- 6 -SUMPS -�-�- LI -Distance to nearest:_ Well Foundation r •�.� .- _ Property Lind -.�.,. DISPOSAL PONOS p I` hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, end rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work lot which this permit is issued, I shall ndto employ any person in such manner as to become subject to workman's compensation Iowa of California," Contractor's hiring or sub-contracting signature °' I certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to tion laws of California." P Y persons subject to workman's compenaa• The applicant must c all req Red ' ctions, Complete drawing on reverse side; I . (415) 429-1724 � Signed D.C. Jeffery Title:SonSt. SUnerinjendent Date: 9/14/90 -• FOR EPARTMENT USE ONLY Application Accepted by Date Area Pit or. rout I spsction by Data D `� Pinel Inspection by Date Gm-rcY - o r r r Additional Comments: 7 0 3J"' Applicant - Return all copies to: t - p SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO D RECEIVED BY j11ATE PEAMIT'No. . Ek 13-24IREV,,i�sr y Ek,4•�e