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:APPLICATION FOR PERMIT <br /> r SAN J',OAQUIN' COUNTY PUBLIC BBALTH SERVICES <br /> ENV I.R.4N1I TAL` IiEALTH DIVISION <br /> P 0 BOX, 2008:, WOCKTON s CA 95201 <br /> (209) 468— 5420 <br /> (Complete in Triplicate) <br /> Appltc.tton is hertby made,to San Joa4ula County for a perzlt to construct wid/or install the vork heron described. This <br /> rppl:Catioa to made in Camphenes vith Un Joequin County Ordinance No. 549 and 1462 and thQ Rules a.AG ilegvlatsona of San <br /> Jc+Cvlp County Public health 3srvttos. AP.OV /Z51-44-0- 23 <br /> Jot) A00iossI <br /> pp City Lot Slie/Acreage <br /> ownat•s Namt eorac ,�CGLi( f 1 Address P,0 oy- $8 .� / PR000 <br /> P 0,isox /Gz�8 <br /> Corwar1D: r1_66__• — Address Soia►x an"t 9.5114 No.&s¢5( - Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION 0 Out of Service veil 0 <br /> PUMP IN$TALLATiQN ❑ SYSTEM REPAIR MOTr1fR 2( Ko storing vClt E� <br /> Sp f, Pr ,4 C,7 S <br /> tJIS TANCE TO NEAFIEST; SEPTIC YANK 462 -- . SEWER LINES 10 ' _ DtSPOSAt FLD d!/, - PROP. LINE X_ <br /> FOUNDATION ,.��_ __._,_ AGRICVLTURE WELL .NlR- OTHER WELL-LO—L— PITSISUMPS „� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> '.1 Inaottial ❑ Open Bottom D Manteca Dia. of Well Excavation 2 Dia, al Well Casing 464 ---- <br /> (4 Domalt+clFrivals . C) Geovsl Pack 0 Tsaay Type of Coding Alow< Specificationsr,.'&1Q <br /> r'l t'.D1+c WoLhor C3 Delta Depth of Clout Seal !�/__l1�'L. .-�.. Typo of Grow 121f/e r <br /> al Ir„U41.0n 12�Appros. Depth ❑ EiYNtn Sutiace Seul Instilled ov,. <br /> AoOait WOtk Oona U Type fol Pump HIP. . Stora Work Dona <br /> 'N611Oetuvction 0 Wett Olameser Usa.ling K&tcrlel li Ddpth <br /> Npth Aller Haterlal i Depth <br /> tyPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIA UITION M DESIRUCTION G iNo sopliC system peemillod it puDlie suwsf is <br /> avaiiWe within 200 loet,l <br /> italion will saws: Residence ..,_, Comtneaeiat Other <br /> Oar of living units: Number of bairooms <br /> ChatlCtaf of toil to 4 depth OS 3 11413 _- —Water tsDlo depth <br /> SEPW: TANK 0 Type/Mfg Capacity,_ _ No. Compsnmenis <br /> ,7KG. TREATMENT PLT;Cal Method of Disposal <br /> Distance to naaresu Well Foundulion — Propeny line <br /> LEACHING LLNE 0 No. 6 Length of lines _ Total tongm/site <br /> ,ItTER BED 0 Distance to nearest: Well t%oun>Srtion ,,__ Proosny Line <br /> SEEPAGE PITS I'I ' Depth Site Number <br /> SVMPS L;t Wsitance to nearest; Well Foundation Property Lins <br /> DISPOSAL PONDS 0 <br /> nstepy zrnity that I have peepared this application and that the work will be done in r.cotoonco with San JoaQvin county oedfnancus, state taws, and <br /> :utas ane ctgutations of the San Joaquin County <br /> nom9 ownif or licensed 1genl's signswrl cortifles the following; "I cosily that in the fytnormnnCe qt %no woof Iol which this pofmit is tssuad, I shall not <br /> or"ploy any pitson in such mannof as to becoms subject t0 woehman's eomponsallon law; of Cslit(atnia," Contractor's hiring of svU.comrociing signatuio. <br /> carlifiat Iht following: "i Lsrttl`f%hal in the periosmance of the work Ips which this permit Is issued,f shelf employ pateons subjoct to workman's CompanW <br /> tion taws of Caliloenle." <br /> tato aoatic+nt saii tyl I requir d insKelfionr. Complete drawing on rrvetso side. <br /> S;pneU Tills: Delo: <br /> 10 <br /> - FOR DEPARTMENT USE ONLY <br /> Dotitslion aptid by J Data Arur <br /> ?it at Grout tnspocilon by Date Final tnepeetion by Data -_ <br /> net Comrn4nt4: <br /> + a.Ot - Return all copies tot BAH JOAQUIH COVHTY PUBLIC HEALTH SSUVICES W <br /> LNYIROHWENTAL HEALTH DIVISION PEUIT/SE11VIvE9 <br /> 445 N SAN JOAQU>N. P 0 UOX 1000, STOCKTON, CA 65201 <br /> W10 AMOUNT DUE AIAOV14T I'MMIY•110 Agit aicelvto ay DAZE PEAklly NO: <br />