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Application Accepted by Z-z Title: 71)rt • Date• pEPARI,FNT USE ONLY ulv-1"( Date APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 L11/0 o 354,0,E iMirRO MA Y 3 J 1995 NMENT/4H I CES PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRO (Complete in Triplicate) PEWIT/SERV Application is hereby made .to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 11 00 Nort-A IA/ i Lon [1/ay City gOck foil , I / I...A 1-30 X ( pi Got Size/Acreage , 7 Owner's Name CXL-7 -Cal Eii I-Pr/4,1152c •IL- Address 0 -ibrt5t,, 6) u Alid, (4 Phon LSIO)C13 - 27/7 i ..)_!30 C 1,1, 1,-,/v )•1 qszc,, Contrac tor ...5fr24.-- tit, PTA EXplitatilddres s -9(7 IT`ilense No.EI2-268 Phone 9'6E -17/I TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ri DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR CI OTHER 4 5,71 i tiri7 Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES > 50Hi DISPOSAL FLD. PROP. LINE 45(4,e-t_ FOUNDATION /7-0f ti AGRICULTURE WELL — OTHER WELL /Oar PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0 open Bottom 0 Manteca Die. of Weil Excavation g" Din, of Well Casing H Domestic/Private 0 Gravel Pack CI Tracy Type of Casing Specifications f I Public Cl Other fl Delta Depth of Grout Seal 0 Tip• of G,OUt1UQfC&41lt I 1 Irrigation XL Approx. 15;p10 I I Eastern Surface Seul Installed by Gn b-. kvlrl bl Repair Work Done L.1 Type of Pump H.P. State ak Done g Well Destruction 0 Well Diameter Sealin Material & Depth Depth Tiller Material & Depth TYPE OF EPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sawer is available within 200 feet.I Instillation willit.,_. Residence Commercial Other __— Number of living units: -------,. Number of bedrooms .-_:- - — - --- Character of soil to a depth of iiieti-,..., Water table depth ' ._ — -- SEPTIC TANK Type/Mfg --tapacity No. Compartments PKG. TREATMENT PLT. 0 .- Method of Disposal .----- ._-- Distance to heernit: . Well ' Foundation Property Line . -_,.....--:._ --. _ - -- LEACHING LINE 0 Lerlitth of lines Total length/size . ...NoA FILTER BED --"j5 - DiStariCe to nearest: Well Foundat i on.. Property Line _._,.----<----- - -- - SW-AGE PI TS. -- ----- I I Depth Size Number .- • SUMPS -. - --- LI Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance rules and regulations of the San Joaquin County Horne owner or licensed agent's signature certifies the following: "I certify that In the performance employ any person In such manner as to become subject to workmen's cornpensatiorilOpeGip certifies the following: "I certify that in the periormance of the work for which this permit Is itsuM, lion laws of Califofnla." The a icant int st call lo ti Inspections. Complete drawing on reverse side. with San Joaquin county ordinances, state laws, and of the work for which this permit is issued, I shell not tnia.','kgriteprs hiring or sub-contracting signature qbmploy peerions subject to workman 's compenu- s-/2_6795— T.) Area C t ( Ut-A-birfa- Final Inspection lay \t61. rkt'Vt vw,a— C 7l i) FEE INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE ( PERMIT NO -) 1,-1. (6 WO C3C i' D 06)(00 1,1t,44 71'' -is Ph or Grout Inspection by Additional Comments: C (Iv c 4 i i\-1 clocv././t_cq Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2000, Stkn, CA 95201 t( Date -)3SD \ Eli 1314 IIIEV. lin 5) EH 1441