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��. APPLICATION FOR PERMIT .a - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES >" ENVIRONMENTAL HEALTH DIVISION `¢ 1601 H: HAZELTON AVE. i PHONE (209)468-3420 ; <a; P O BOR 20091 STOCKTOHi CA 95201 s • -ti.j $ >vrm E%PiRES YTs R FRY DATE ISSUIMI? ,:.:� S,. V. (Complete ift Triplidate) Applici4tidn ii hbreby oiade to San Joaquin County for ti peizolt tb contsti•iict acid/or initA11 the Work h1tr le Ae'tioi6fidd. This :'1 application ie mat iri comrpliance with Sen Joaquin County Ordihince tfa. $40 And 1$62 and the RuleA "A 949dlAtirsfili of San �) Joaquin Canty _Pub i pHh�a� ervlc /Vh j t�/►Ts,,C>'-I" lrE7ity !V Lot size/Acreagiii U2 Job Address Address � 1 — - Phone Owner's Name Contractor Address 5� s�- Licen§e No. hoi+e�6171097 TYPE Of WELL/PUMP: NEW WELL ❑ WELL RDESTRUCTION ❑ Out oP Service W EPL CEMENT ❑ ell ❑ . PUMP INSTALLATION 11 SYStEM hEPAIR 0 OTHER ❑ f+loni'ttai�ing We31 V j DISTANCE tO NEAf� tt SEPTIC TANK SEIIUEF LIiVES 1a1SP6SAL PLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA`, CONSTRUCTIdN,§PEC#FICATIONb r C1 Industrial ❑ Open Bottom ❑ Manteca ' 1116: of Well E,�cavaiiori Dia. of Mil 8heilig *S EI Domestic/Private El Gravel Pack ❑ Tracy _Type of Casing ,o, Specification3 i'I Public -- ttr 1-1 Other fl Delta deptH iif Cir6u"t Si�I 1' - Type of Grarll *•: �F' .;s.i, i I I Irrigation _.Apptox. bepth I I Eastern 1 Surface Setil Installed by1 t "� 'F Repair Work Done .0 Type of Pump H.P. a --- Stale ljtlork sons_ - = C Well Destruction ❑ Well Diameter i-} See.].iing f4ate'tiel`>fl 1) tfi >r•• t �}� ; I c Fitter ldeter li �. pth _2 i Depth TYPE OF SEPTIC WORK:-,.NEW INSTALLATION I I `l REPAIR/ADOiTIO DESTRUCTION I 1 1No septic system permitted it public tdwbi is il ; t l V available within 200 feet.l s Installation will idive: Residence Comliietdial n Other •' , :, Number of living;whits i P" Number of bedrriarits " � r � r -� . r.; Character of safi;to a depth of 1 feet: l 4 `-' Wifbi table depth'.: Ei : t SEPTIC TANK i Ci. ,.Type/Mf j QA � Cr,N�g-0-4:� .-csft'h lty ll . CIO S NS. Coriipertritents PKG. TREATMEN PLT.Cl ! l "' Meitlod 61 pitpoisal DistAnce,ta nearest: 1 ttT Ati6h 1-�_r.Proodrty Unb f ! LEACHING LINE i 1 . Nd. its Length of lines Total"FeligthJslxe 1 ! Q��~ FILTER btD r❑ ' Distance to ndartist: f Well awn t7 ProrlA v Lina i SEEPAGE PITS 11 Depth 3_ j Sit Nurhber Distance to neireat: aund6t ion PropNrty One DISPOSAL PONDS ❑ il,14 te4 CQ�� } ° I hereby certify that I hand prepared this appiic p/id the the work will be done InA4cbrdance with San Joaquin county prdinariaiij elite laiiv9,and •�t• rules and regulations of the San Joaquin County Homs owner or licensed agent's signature certified the following, "I certify that In the performance of the work for which this petrriit is lasued, f 'theft not employ any pe►son In such mAnner as to become eubjeit to workman's compensation laws of California." Contractor's hiring of sub-coritracting Vonsture r certifies the following:"I certify that in the performance of the work for which this permit Is issued, I shall employ parionfi subject io*oArnin's eompensi- tion laws of Callfornia." the applicant must call for all requp'ed nspOction6. Complete drawing on reverse side. ` Signed X` /J'-!�'` : @��' '��title: • - ----- - -- - Dai9: //P,/ U t , ,7 IR DEPARtIV1EW Use ONLY Applicltion Accepted by -= ' Date Area Pit ori Grout Inspection by bate Final Inspection Additional Corriments: Applicant - Return all copies tot Stir Joaquin County Pubile HeAlth s Servicers, Environmental Hehlth Pdridt/SerV-icea 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 F iFl AMOUNT DUE OUNT REMITTED CASH RECEIVED BY PATEp� 140. FEE . EH 13-74 JAEV.It n 5) 4. l V CJ ZA(� {^ `� 1� �` V V .A i EH 14-ie i+