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t <br /> e- APPLICATION FOR PERMIT <br /> S <br /> BAN JOAQ�IIN COIINTY PUBLIC HE fi D� Y �VICES <br /> ENVIRONMENTAL HM <br /> SAN JOAQUIN COUNTY-PUBLIC301 N wVS., PHONE (2 �' ?fl <br /> aos, sTOc;s:'rort, CA �a�, . '�►'� <br /> ENVIRONMENTAL HEALTIi DIVt I Vd� `�J�r. 4 '0? <br /> SPECIAL FE � c <br /> (Complete is Triplicate) T ��1 Aypl3cacsoo At <br /> to hereof o>ade.to San Soa4uln County for a qes-mit to aoaatruct aedror ipato•1]• the v !ad tl+intCovucy RsbZicnxealtEBrr3caehflan Joaqula County O,dlpauce Ra. 549 sad 1862 and the ' PERMIT ffil� <br /> a1 City �cif?1"' Lat SSze/Acreege <br /> Joh Address Iv { JAr-"C" S7'140ffaCT-T <br /> rt/G Address <br /> KC. A 4 Phane7r�r"�91-3C <br /> Owner's Name .30,63 07slEG C11Z�AAc�Sui7iE qr G <br /> Contractor <br /> YL"At&-6 Address_1�11NchE� dao• C License Nn. .�I���B_Phone yfa <br /> TYPE OF WELLIPUMP: NEW WELL WELL REPiACEMfNT Cl DESTR OTHER 0 TION U �t Wnitoring well pf <br /> ❑ ° <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ <br /> DISPOSAL FID. PilrP.LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> TypC^Op� PROBLEM AREA COkSrRUCTIpN SPECIFICATIDNS :/ / <br /> INTENSE Dia.01 Well Casin y / <br /> ❑lndualpal ❑Open Bottom ❑Manteca DIF.of Weil Excavation Specilicaiiona�,. `/7L.L <br /> Gravel Peck ❑Tracy Type of Caging <br /> I'1 Public iclPrlvate ❑ Type of Orout���0�ii ls/raT / <br /> i'I Public <br /> M 011ier Fl Davis Depth of Grout Still �� <br /> y. <br /> I I Ivigariort .APP+o°•Depth I I Eastern Surface Seal installed State Work Done_ <br /> Repair Work Done I3 TYPI 01 Pump H-P• ub ➢ <br /> Sealing ir� rlal eQth -- <br /> Well Destruction ❑ Well O1ametatO Tiller yateriaL i Depth / - <br /> DePIh <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INa av�+iabte 019zavtwithin 200 lsYerOm peennted if ---public srwrr is <br /> eat.l <br /> } <br /> Installation will serve: Residence— Commercial,_ Other— <br /> Numtwr as living units: Number of bedrooms <br /> Water rebk depth � <br /> Character of golf to a depth of 3 110411: -- Capacity___— No.Compartments <br /> SEPTIC TANK 0 Tw*/Mfg Method of Disposal <br /> PKG.TREATMENT PLT. <br /> Distance to neeren: Welt Fovndetion [,?6'tV LI^° <br /> p — Total tengthnize <br /> LEACHING LINE ❑ No.6 Lanptm o!tinea Picpony Line <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Number <br /> SEEPAGE PITS I I Depth Sirs Property Line <br /> SUMPS LI Distance to ntarest: Wall Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certity ths11 I have pjepsred this applicauan and oat the work will be done in accardanu with San Josqu•n county ordinances,state lows,and <br /> rules and regulations of the San Joaquin Count? <br /> Horne owner or(Peened agent's signature certifies the fouow ng;"t terrify that In the performance of the work far which this perm 1111 iatued,!shall not <br /> emplay any pKson in such tnenner as to baceme sublect to workmen-s compensation laws of Calilorn o ors env acting signatuie <br /> certifies thr rmwhi <br /> following:"I certify that in the pedoanca of the work Ior which this permit is issued.I as rkmart's C1A mP*r%u- <br /> Flom laws of t alilomie." <br /> The applicant mutt call for aR required less pons.Complete drawing on raysera aide. 3 <br /> Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Appliwtlon Accapted by I ` <br /> se11e [ Final Inspection by,_„ Dau <br /> pit or Gtout Inspection by <br /> fi� I <br /> Additional Comi tent°: (� {, <br /> sly tide toe Baa Flies County fuhlle Saslth ��i <br /> _ _.. _... .. _ <br /> Applicant me"Um op pieslaee,-Eoriroa=ntal-Raalth PernitJSenleer <br /> 1601 E. 8atelton Ave., P C Box 2009. Stnektbo. CA 93201 5T— <br /> ;?PERMIT <br /> AMOUNT 021£ AMOUNT REMIttEO CAS N RECEIVED BY oAtE(� PERMIT NO. <br /> t�INFO ti ! !yI - <br /> n r7711nEV.mr+lr M�C� i.ti��00 ``77 f! <br /> H 1 M t <br />