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City 1-oej Los Size/Acreage . <br />Signed .0..it%714 atA/LA II Title. <br />APPLICATION FOR PERM IT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERV I <br />VIRONMENTAL EiEALTH DI VI 41 t <br />445 N SAN JOAQUIN , PHONE (209)468-U <br />EN 0N) •x <br />Y 40.g v40 " " <br />( Comp <br />P 0 BOX 2009, STOCKTON , C <br />te P 1 <br />FWV# <br />9-n_3 <br />Application is hereby aside to an JosKitio County for a permit to constrUct acid/or initall the work <br />sPielication is swede is cosiliance vith Sao Joaquin County Ordinance No. 549 and 1662 and the Rule*and Ri Josgelo County Public fiealth Services. <br />Job Aticheut_eaalS .gertieVio,2 I--gt e. <br />of San <br />-....-- i . <br />Owner'. Name 1-.11.3 C_.. it /I k 4-ind . Address a CS,,nNi. -1 7c-i <br /> <br />-Del 1 Phone _I , 1 1 r...‘ . , 1 . <br />Contrzcto: .1/ it I Irl v Lx)...., ifiv,4 Address Pi) . a4:91:i.. 4/..Q.1)4( isr,cens,sa. ?,,..elioq - •D-77, <br />TYPE OF WELL/PUMP: CIEW WELL 0 WELL REPLACEMENT 71 DESTRUCTION Out of Service Wail n <br />0 PUMP INSTALLATION 2 SYSTEM REPAIR 1_2 OTHER 0 Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANK neiNe SEWER LINES DISPOSAL FLO. PROP. UNE <br />FOUNDATION AGRiCULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />:7 Industrie? 0 Open Bottom 0 Manteca Die. of Well Excavation Dia. of Wee CasIng <br />T, Domaine/Private 0 Grovel Peck LL.1 Tracy Type of Casing Specifications <br />Patric Cl Other n Delta Depth at Grout Seal Type of Grout <br />/ induation --- APPrOk. Depth i I Eastern Surface Seel Insioneo by <br />Flepitt Work Done L2 Type at Pump HP. tete Work Ion. .. Watt Divinruction lik. Will Diameter I 11" Sealing Material a Dath rik <br />Depth i "N Cl 1 Fill.- Material a Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLAT/ON I I REPAIRIADOMON : i DESTRUCTION t I ;No septic system pa-emitted if public sewer 4 <br />evailabie within 200 teeci <br />Inateilabon wiii saner Ressdenos , Commercial Other <br />^ <br />Number of living units- _ Number of bedrooms <br />Character of ace to a .21•Oth of 3 feat Water table depth <br />SEPTIC TANA D Type/Mfg Capacity No, Compartments <br />PKG. TREATMENT PIT, 0 Method of Disposal <br />Distance to nearest: Well Poundafton Property Line <br />LEACHING LINE Cl Na. g Length ot lines 'Total length/size , <br />FILTER BED 0 Distance to fleetest: Will Foundation Property Line <br />SEEPAGE PITS i I Depth Size Number <br />SUMPS L I Distance to nearest: Wait Foundation Property Line <br />JISPOSAL PONDS 0 <br />rule* and regulations of (ha San -lois:win County <br />Horne owner or licensed agent's sigruseure certifies the foilowingi "I candy that RI the performance of the ryork for Much the permit is issued, shall not arnPlaV any aaraon in such manner r4 to become subject In workenar‘'s combantatiOn laws 01 California " Contrectoes hiring or sub-contracting signature conifer the following: "I certify that in the performance at the work for which this permit is issued, shall employ peradorla Subject to wort/nen's combenu. laws of Catifornia." <br />accordance with San Jateduin county ordinances, state laws, and <br />FOR DEPARTMENT USE ONLY <br />Date <br />Date In <br />Application Accepted by <br />Plt or Grout Inspection by <br />Acktroonei Commenta <br />Date: <br />Area <br />Date / 4-7 <br />1A6 <br />lei 13-N (allV <br />14-21 <br />Aprlicant - Return all <br />" - <br />40/X)429,j, <br />copies to: San JOaguln County Public Health Services <br />Environments/ health Permit/Services <br />445 N San Joaquin. A 0 BO* 2000. Stan, CA 95201 <br />I FE/ 1 <br />i iNFO <br />Amoufer 0.1 ' AMOUNT REMeTTED <br />+ <br />ck-TO <br />CASH RECEIVED SY DATE <br />r-- - ,/ <br />IU , D1 i i 60 .c4) &n.00 1L-3;.- 7. /4 „ /////93 <br />The &dilatant roust Call /Or 400 required " pections. &motetø drawing on rev