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APPLICATION FOR PERUIT <br /> SAN JOAQUIN COUNTY PU13LIC FLEALTH SSRVICRS <br /> I•:NVIRON.W NTAL ILEiALTH DIVISION <br /> P 0 BOX 2009 , STOC;KTON , CA 95201 <br /> (209) X68—fle4 ¢.'�/•� <br /> PERMIT E12Ii3JO,1„U,Q,4 PROM DATE-10,91M <br /> (Complete lu Triplicate) <br /> Application Is hereby made to San Joaquin County for a Permit to construct and/or install the work herein described. Thio <br /> application is oado in c0apIlance vith San Joaquin County Ordinance No. )69 and 1862 and the Rule& and Regulations or San I <br /> Joaquin County F"ubllc Health 9ervlcea. <br /> Job Address IC tY1 tL _v� Cny _ � f)� Lot alts/Acreage C�'I / J <br /> Owner's Name � tt —� ICA- Addreoe v �m�r� `�G�f _ Phone -rojfZ <br /> 6C L-A <br /> Contractor ��-.✓CG_►n��)•C &0 JO 6/✓,k�7 _ License No Y1L_LV 3 Phone S <br /> TYPE OF WELL/PUMP. NEW WELL Cr' WE�CA1 rLaCC,"nt it OESIRUCTION 0 Out of Sorvlcc Nall <br /> PUMP INSTALLATION 0 SYSTEM F FPAIH 0 OTHER 9 C/� monitors g s�cll <br /> �- �h C r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PgOP. INF. <br /> FOUNDATION AGRICULTURE 'NELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PA08LEM AREA CONSTRUCTION SPECIFICATION m <br /> Ll Industrial O Open Uottom O Manteca Ore of 'Nell ExC&vAt.on /_ Dia. of Well Casing a 75/&.t <br /> U Domestic/Pnvato Cl Gravel Pack 0 Tracy Tvpe of Casing. "5_4-eel , Speullcauona. _ <br /> O Public I') Other O Oolto Depth of Grout Seal Type of Grout `� �Ott�t/t rtG <br /> CJ IrnUatton _ Approx. Depth 0 Esiwen Surface Sell Installvd by fct4tii Nrk1l(""I Wk 4j <br /> Repair Work Done U Type of Pump H.P. State Work Dona _ <br /> Well Destruction O Wall Diameter 3ea.IIn4 Haterial i Depth <br /> Depth Tiller Hatertal L Depth <br /> TYPE OF SEVrlC WORK: NEW INSTALLATION L) HEPAIR/AODITION CI UESIIIUCTION Cl (No eoplre ays(orn permited d publrC sewer ra <br /> avariable within 200 foot.) <br /> Installation will servo: Rssidance _ COmmerCi&I _ Other <br /> Numbly of living unite: Number of bedrooms <br /> Character of loll to a depth of J het: Water table depth <br /> SEPTIC TANK O Type/May Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Wall Foundation Property Line <br /> I <br /> LEACHING LINE 0 No. & Length of (Ines _ Total length/site <br /> FILTER BED Cl Distance to nearest: Won Foundation Properly line <br /> SEEPAGE PITS ( I Depth Stre Number <br /> SUMPS U Distance to noaraw Well Foundation ` Property Line <br /> DISPOSAL PONDS (7 <br /> I hereby cerltly that I have prepared this appl.canon and that trio work wdi Lou donu n accordance with Son Joaquin county ordinances, stele lows, and <br /> rules and regulations pl Ins San .Joaquin County <br /> HOMO Owner or hcenaed agent's signalure Ce(trhot tho fgilowing 'I cortrfy that In the pnrlolownce of the work lot which this permit is issued. I shall not <br /> employ any person In such Hunner as to bocomo aub)oct to wor,men's Compensation laws of Colilornw- Contractor's hiring or sub•contracting signotwo <br /> candles the following: "I Cenify(net to the porformance of trio work for which this permit is issued, I shall employ persons subject to wotkman's companu• <br /> tion law; of California." <br /> The applic& s `II for/a" <br /> >"ird(l ntoections. mptota drawing on !averse idr. <br /> Signed / .. // nh: � �.C_ Doth: <br /> FOR,DEPARTMENT USE ONLY ( 9 l l <br /> A pllcatlon Accepted by Data c_3 / 1 Area q36 <br /> PI( Or Grout Inspection by—77? J Oate3l"Z Final Inspectle,n by lam( ' ` Dats f <br /> Additional Comrrrntr. � /��,,� ,,� <br /> AppllCUL ltaturn allp"itis( tot SAN ACt�IN Ot1N PUAI.t 1tBALT1 1 OEtiV1Ei9 - <br /> ENVIRONLFHTAI. )If: LT11 DIVISION PERUIT/JERVICEJ v <br /> 445 N JAN JOAQUIN, Y O BOX 1000, ST<x:XTON, CA 00201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT nEwr`rf CASH A(Cfrvto DY DATE PERMIT NO. <br /> I <br /> ns 1]•71(AIV <br /> l d _ _ _ i �_, t ! • _ 1.10 J 2 <br />