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APPLICATION FOR PERMIT � V� v SAN JOAQUIN COUNTY PUBLIC REAL,TH SERVICES ENVIRONMENTAL HEAL'T'H DIVISION ' P 0 BOX 2009, STOCKTON , CA 95201 (209) 468--3447 UMIT EXPIRES-.I YEAR (Complete in Triplicate) epPlIcatlon Is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This aPPlication Is made in cowliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Jeequin County Nblic Health Services, ' Job Address /goo EPvST FR E-M 0AJT- ST- City 5-rV"_F_0d Lot Size/Acreage _ fUTZC _ f tAJ ES> Owner's Name )4[)R-- CAL � -VtF-A(DI- Address _ _Z 2- rJ70A/� [j4✓� 'A 3-7Z10600 ., .,. .�..� ____ Phone KL�,uFEt_n�� z Bz5 iE. ►��zTt � G5. !z Centfacior—� u►Nl COtJtTlai�ddress License No. P'honeZ0 `�bs` Tr PE OF WELLIPUMP. NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ SOIL f�t)p_ foS PUMP INSTALLATION 0 SYSTEM REPAIR C1 OTHEEo Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK + 50 •SEWER LINES '4 50 V_ DISPOSAL FLDJ 59t+--PROP. LINE 1C)t-T' FOUNDATION f 55 • AGRICULTURE WELL `L 52 OTHER WELL If-L, PITS/SUMPS `s 5D INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ( ! Indusrrul CI Open Bottom O Manteca Die. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Peck U Tracy Type of Casing_._,—_ Specifications rl Public I 1 Other ❑ Delta Depth of Grout Seat Type of Grout rl Irr tlation __ Aoprox. Depth ❑ Eastern Surfacre Seal Instalasd by ` Repeh Work Dona L7 Type of Pump H.P. State ork Oona _ \Will Destruction U Well Diameter Sealing Material i Depth SAND CEMENT" -Ota f mrNrrru �7b CMLMrCAI 7 I 4r- SOIL Depth Filler Material i Depth 5AE1ntL_ RS A V§f , gEOTOIJITE _ TYPE OF SEPTIC WORK NEW INSTALLATION L1 REPAIR/ADDITION nDESTRUCTION GI 1No septic system permitted if public sower is available within 200 lest.) Installation will serve: Residence __ Commercial_ Other Number of living units: Number of bedrooms Character of Boit to a depth of 3 Feat: table depth SFPTIC TANK 0 Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. 1=1 Method of Disposal L�\ Distance to nearest: Well Foundation Propeny Line LEACHING LINE I-i No. & Length of lines _ Total length/sizee FILTER BED CI Distance to nearest: Well Foundation _ Property Li D SEEPAGE PITS I I Depth Sire Number JAH 21992 ' SUMPS LI Distance to nearest: Well Foundation Propenf��e� LINTY DISPOSAL PONDS 13 PUBLIC H I it BWCES I hereby certify that I have prepared this application and that the work will be done in accordance wit �nkfr� ��(ai�� taws, and rules and regulations of the Sen Joaquin County ' Homs owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shatl not employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting s gna"ire certifies the foltowiny: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's Compensa- tion laws of California." ' The applicant Aiust call for all rd'gAW*d inspections. Complete drawing on reverse side. Signed X Title: /' 1 •' �' Dara: 1--- r FOR DEPARTMENT USE ONLY ' Application Accepted by f Date Area Pit or Grout Inspection by Date Final Inspection by Date Additlonat Commants: _ - "T'licant - Return all capiee to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES " - — ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, p 0 BOX 2009, 9TOCXTONCKTON, CACA 85201 ! 7 11 TEE AMOUNT. DUE. AMM)NT REMITTED Cir CEIVEO BY R rfIFO - SH DATE PERMIT fVO. Of 112, rAFv ,,.�, �9.UD p.w_