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WEST HH'19HT DRILLING C07'0. PHONE Ho. 916 636 7276 Ju 1. 18 1991 9:Opti• PO-4 APPLICATION FOR PRILMIT SAN.JOAQUIN COUNTY PUBLIC HRALTLI~SERVICES LNVIRONM NTAL HEALTU DIVISION 1601 E. IIAZELTON AVE. , PITONS (209)468--3420 P 0 UOX 2009, STOCKTON , CA 95201 I'MWIT EXPIRES 1. R-YROM PATS ISSU9 Womplete in Triplicate) Application to hereby made to San Joaquin County ror a permit to oonetruct and/or tnstall the work herein dceeril.cd. 4r,fn spplloatlon is made In ooWlianoe with Ben Joaquin County Ordinance No. 5L9 and 1662 and the Rulef, rued RrgulaUuuu �r Bu'. JeAqulln Cnunt.y IA0,110 Realt.h Services, y�{J Job AddraF/ CJ/ t�t ( f City L� 1YL Lot Sl re/huruue, t�owner's Name L�y ` d 1 _ Address t ontraCltlr . �� .�.r?�A2 Address G �.► '` (�� _ LicenseJNo.� i J.Z. Phnnr(��*?Z ._.. i ._. TYPE OF WELL/PUMP NEW WELL LI WILL REPLACEMENT Fl� OCS111UCTION Ll Out of Sorvlcc Well t:) PUMP INSTALLAT�Irf O SYS EM REPAIR O OTHER Cl Monitcring well yL DISTANCE TO NEAREST: SEPTIC TANK DIL�I .. SEWER LIN Sr RISPf)yAl flp,�!/fit PROP. LIN(: �b e FOUNDATION --- -- AGRICULTURE WELL h`I�/'�_ OTHEA WELL Aja PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CON$TAUCTIO_N SPECIFICATIONS _ '/^41 I I Industrial U Opan 8ettam O Manteca Dia. of Woll Ekcavaalnlion� r7 Dip, u1 Well Cnoltl � (I Domasnc/Pfivste U Gravel Pack (-I Tracy Type of Casing_. I�r V, , Specifications CQVIN 1"I Public 1b-1_Othor I-1 Della Depth of Grout Seal ,. Type of Grout I I ImUalfon C�I Applo■. Dep flI I Eastern Statics Soul Installod by _ _ � m bit 11h Repair Work Done U Type of Pump /y,AH P. _ State Work Dona _ �_ Well Destruction Cl Wall Dia,_mact�ar �� Sealing Material i Depth ay DepthLa_..$�_� Filler Material L Depth TYPE OF SEPTIC WORK. NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I lNo &optic system perminud it public suwar rs_. Avoidable within 200 laoi.) \ Installation will serve Residence __ Commercial___ Other _ Number of living units: Number of bedrooms Character of soil to s doplh of 9 last: - —_ - -- _.Water table SEPTIC TANK O Type/Mfg _ -�~�Capacity_.. PKG. TREATMENT PLT. U Method of Disposal - _ Oislanca to nearest: Well -` - - foundation Property Line LEACHING LINE Cl No. & Length of Imes - - - --_ � _ Tolal longth/siro---- FILTER DED CI Dletence to nearest: Well Foundation -- Property Line SEEPAGE PITS I I Depth _.-_-__Siro _— Numbor SUMp5 Cf Diolance to nearest: Wall ro Foundation Property --� - _ pe y line _----- _-- DISPOSAL PONDS C7 I hereby cenlly that I have prepared this application and that the work will be done In accordance with San Joaquin counly ord nances. stare Is. >, anti rules and regulations of the San Joaquin county Home owner Or licensed agent's signature certifies the following; "I certify that In the porfurmancl) Of lhu work for which lhra permit Is issued, I Shall nut employ any person In such manner as to become suhlect to workman's compensation laws of Colitnrnra." Conlrector's hiring or sub contracting s%gnetwe candies the following: "I certify that in the perlormance of the work for which thla permit is issued, I shall employ parsons subtoct to wr Arnan's cuntpansa tion lawsf alifornis." The applie t must cell for all requiryslinaps�Wos. Complete drawing on reverse side. ('] C� Signed X_ Title; � _......_ ----- !)eta'�� y- / / R EPARTMENT USE NLY I I Application Accepted by �r �:1Q� Date 4-- � Area Zo Pit or Grout Inspection by Final In&peotsvn by Pats Additional Comments: Applicant - Return all copies to! s4m Joaquin county Public Health Sarvluen, Ftu�lrorwwnttal Nealti,r Permit/Service, 1601 F. Raselton Ave., F 0 Dox 2009, Stockton, CA 95201 FEE AMOVNT DUE AMOUNT REMITTED CK NFO RECEIVED 41' DATE PfAMIT N0. ICAS • tH J i' tato •n&I Y7/