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-F �- ._ R :. APPLI CATI ON FOR PSRM I T D SAN JOAQUIN TAPUBIi 1C HEALTH SERVICHS v L ILEALTH D I V I S I ON CpUN1Y- OVA 9, STOCgTON, CA 85201 l 2 !991 SAN IOC KQ2INvEM&I. irf'209) 488— c� ?- -3`f O (Complete in Triplicate) j �SL1�I2 cate)_JDATR Agplitatlen 14 hereby :a4e,to L'an ::aqulo County for a perms— to construct •rd!:r itstaill the wort herein described. This ap,lleat'-Ca Ss ra a 1n tr_,,.11ar.tt with San Joaquin Cocnty Ord1:[nce Yo. 544 and 1662 and the Rule■ and Aesulaticns of San Joaquin County Punic Health Services. Jab Address SdU Sa�T"h - GeNY.t GCity Le'1. . ._ Lot Sixe/Acree�ye s8,UVyf�Z S2 5 tv,-r.- rk.-re Srrc c:, lay - S8z- ra rn...r r, L� Address _ 1 to F�-.� G _ Phone OZ tel Ownnr?Name� —_.'._ /t E r• rc w n c no C t7 r G7[t� 'f'- 7 Ccnuacter 'Qt;L.K`�[ ._ _Ad^-tees tC3 �gCr%G 1GL,—1.cerse ho. 511 Ciel PeoneJta�`�.7c7C TYPE OF WELLIPUM.P NZ'.Y'.'rELL - 1 .TELL REPLACEAIE'4T r.; CESTRUCTION ❑ Out of Serrlce Ve21 ❑ PIMP INS ALLATICN ❑ SYSTENI REPASR ❑ OTHER ❑ Honftoring Well C� DISTANCE TO NEAREST: SEPTIC TANK N'} f`WEA LINES 401}r1 DISPOSAL FID. 'fl PROP,LINE }may Juu` AkW-L3`%y,✓-Z6 FOUNDATION AGRICULTURE WELL :±_ OTHER WELL 'r✓` PiTSISUMPS �4 INTENDED USE TYPE OF WELL PAOBLENI AREA C014STAUCTION SPECIFICATIONS h f7 Industrial 11 Open Bottom G Manteca Dia.of Wall Excavation. LS" ___ Dia.of Well Casing L OomesticlPnw[e ❑Gravel aacx 0 Tracy Type of Caging Specrllcations ❑ Public Cl Other C OeI[a Qepth of Grout SNI " 6,/SFr Type of Grout IV"'- Cj Irptidbon 7'S`�)rApprox. Depth 0 Eastern Sw0ce So,[IAstall'sd t;�. Repair Worse Done L7 Type of Pump H.P.� Stara Work Dene Well Deatfuctian ❑ Well Diameter �a Sealing Hater Sar. a Depth .gnat C4+ :L—.0 sru'/Jug Depth 7r il`4cT.11er MatesIal A Cepth hCr�rsrws T"7n-__SF-- .. •yV-Yr�3r+'..(rJ� TYPE OF SEPTIC WORK. NEVI INSTALLATION 0 REPAIR IADDITION DESTRUCTION w.I INo septic system permitted if public Sower is :variable within 200 test.) Insulation will serve: Residents Commercial _ Other Number of living units:_..._..: Numiw of t:-edrooms - - _ i Characlor of Foil to n depth of 3 feet: Water table Copth P. SEPTIC TANK ❑ Type/Mlg Capacity_ No. Campartments } PKG.TREATMENT FLT,❑ Method of Disposal Distance to nedr-sl: Well Foundation_ Property:inn LEACHING LINE 0 No.b Length tit lines TCral length/sire. FILTER BED ❑ Distance to nearer.: W0 Foundation Property Line o SEEPAGE PITS I I Depth Sire _ Number SUMPS Ll Distance,to nearest: Well Foundation Property Line ° DISPOSAL PONDS 0 f I norsby certify Inst 1 have prepared this appiication and that the work will be done in accoroa ce with San Joaquin county as In c tall,,*[ata taws,and 3 rusas and r"uiavons of the Gan Joaquin County F`a Home owner or licensed agent',.signature Camhes tho fojlow+ng."I certdy that In the Lurlcrrrarce Cf the work for whist this permit is Issued,i Sha+not employ any pampas In such manner as to betpmo,sub;ecl ro workman's cPmpen34tlan[g.vs c'Catfdfnla."Contractor's lupng or sub•conlr cling signature 1 Cenrfies the following:"I certify that in the performance of the v,erk far which this permit is issued.t shall emPluy parsons subject to watiman's compenit- lion laws of Calilufnls." .11 T;iv applicant must call for all required irrpScrior.s. Complete Crawing on raverse sica. Signed x /I. YJ•,�tt«c ,L✓fix i Cil.. T;tle: SG-[ .'fir G-<✓l• rf� f cl- i S Datb: } ' FIOH DEPA T T USE ONLY bilk Application Accepted bye! Dara ---�- yV_ Area Pit or Grout Inspection by Dass Final Irs?ection by Date Agdilional Comments:. - Applicant _ Ae sro all copien to: Sl..ti J1AQU1N CCUNTY PUBLIC IMALTR SERVICES 4• ErVIRONWF_'iTAL HEAL.H.DIVISION PERVIT/SERVICES 4.15 N SAH JOAQUIN, P 0 BOX 3C09, STWKION, CA 95201 CK 8 FEEAMOuN7 Utile AMouKT REMITTED CASH+ RectiveD v, DATE PERMIl NO. INFOdf ......... � # / 71JG'LJ l�%�� f_ `f� /` • r. l RODLCnrw �f _ + DWi . ow a �j :