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FROM 11/28/90 18: 06 P . 9 � .,PPLICATION FOR PERMIT SAN JOARUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION =y-1 ,,r-+. p 0 BO% 2009 , STOCKTON, CA 95201 D (209) 468 .3447 Ute 1 IgQQ PRAMIT --xalA.',au DATE ISSUED (Complete is Triplicate) IJAiIENTA- HE }� Applicatieo Is hereby nada to Bao Joaquin County for a permit to construct and/or Install the work �H2t"M/O/aUipkYSMdAL"fila applic►tioa is aedo in ccupliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rulas wind Raiulatidtla of San Joaquin County Public Health Service@. Job Address City S'4 L Lot Site/Acreage ?nye_ Ownefa Nanno c rnon��rS Address Pao lla 1 ,17- Glr✓.�L c. t�,Ll •,-- Pnon� 4��•G. �yaoi Conllactot rck,�i Address 1�'� U #,� License TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION d Out of Service Wall Monitoring Well PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER O ltv DISTANCE TO NEAREST: SEPTIC TANK AJC SEWER LINES •?;Myo, DISPOSAL FLO. AIA, PROP. LINE --aj;2U FOUNDATION l0 AGRICULTURE WELL -4L&--- OTHER WELL Ab /- -- PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS g z r C1 Intlusirial MD k 0 0 Bottom ❑ Manteca Dia. Of Well E.cevetion � Dia. of Well Caging `o PV�- Uq �/ ?U( •UZ Slo y}�l specifications c c U Domestic/Privs�a / Cravat Pack ❑ TncV Type of Csaing1 W 0 Pabfic 1'1 Other 0 Delta Depth of Grout Seal / S -- Type of Grout rJ Irrigation _.Appros. Depth 0 Ergarn Surface Saul Installed byfC ;-/Yo)Q1 Ltk't�✓� Repair Work Done U Type of Pump H.P. State Work Dona _ Well Destruction 0 Wan Diameter sealing Material a Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTACDJ tiON 0 AEPAIR/ADDIT10N 0 DESTRUCTION G (No seplic system permilted it public sower Is available within 700 lost.) Inpaision will serve: Residence_. Commerclol _ Other / NumWr of living untie: _____ Number of bedrooms Y Character of Goll to a depth of J toot: Water table depth :7 SEPTIC TANK 0 Typa/Mfg Capacity No. Compartments PKC. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line Z LEACHING LINE 0 No. g Length of linea Total length/size FILTER BED M Distance to nearest: Wen Foundation Properly Line gEEPAGE PITS 11 Depth Site Number SUMPS LI Distance to nearest: well Foundation Property Line DISPOSAL PONDS 0 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin county ordinances, Nate laws, and rules and regulations of the Sen JOAgUA County Home owner or licensed agent's signature cemflp the following: "I certify that In the Dertormence of the work for which this permit is issued, 1 shall not employ any person in such manner as to become sub Hot to workman's compensation laws of California." Contractor's hiring or rob contracting signature CPNl4a the following: "I certify that in the parlvmenco of the work for which this permit is issued, I ahsll employ persona subject to workman's COMOOMsa- tion 4ws of Glllor / The applicant CAR it o for all regv�l '. Ctlo (. Complete drawing on (evvaras, aide. Signed Title: A- - Dole: • FOR DEPARTMENT USE ONLY f Q/1 Application Accepted by Date J/" Area Pit or Growl Inspection by Data I Final Inspection by L _ Data l Z!-4q Additional Comrtvntc ply A.pplleaat - Return au copies to: ENV RONMENT L HEAY HSDIVI NSALTN MIT/SERSSNVIJOAQUIN L HRALTN BLIC HEA PAItSERVIEHVICE9 448 H SAN JOAQUIN, P 0 UIOK 7000, STOCKTON, CA 90201 F7—;-RE-1- AMOUNT DUE AMOUNT REMIIYfC OASN REC Civic) ay DATE PEAMIT NO. FOZleO r IN 044 lacy,11411 4//•f"`' 1L IDS _� 1 - 1� �t.�^ EN U•al