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• i APPLICATIOta FOR PERUIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Eh'V I RONYENTAL HF A T TH DIVISION <br /> 445 N SAN JOAQUIN , PHONE (209)46$-3920 <br /> P O BOX 2009 , STOCKTON , CA 95201 <br /> PERMIT I R YEAR EROW &T <br /> (Complete in Triplicate) <br /> Applieatloc is hereby made t.0 Sao Joaquin County for a permit to construct and/or install the work herein descrlbed. This <br /> aypllcatIOt is tmdr it compliance with San Joaquin County Ordlntinee ho. 51i9 and 1862 and the Nales and Tegul.ations of San <br /> Joaquin County Public Iiealth J3erv1ees. r <br /> r 3q SI^e:7h' GEN'f'['`/' ST ��r City�iEC/:Td•.1 t,ot Slim/acreage N! '' .$ T <br /> Job Address 07 <br /> Owner's Name CJS c,"�0 dS i Address <br /> ,1 �/rm0P) LJI Phone 5 L 70q S-00 <br /> Conifaoor GAEC G ��i��J,r�J Address �50 aW h�TlNr C1it Slb� Pnpne 1 <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT M D TRUC71 n Out of Service well [1 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER IAonit.oring well 0 <br /> Spl� B^/:J�✓�S <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP � P. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ci Industroal ❑ Open Bottom C Manteca Did. ofgeYak scavatton ` Dia. of Weil Casing <br /> ,'I Dome stic/Prows le DGravel Pack ❑ Tracy Type of Cooing Specifications <br /> i'I Public Cl Other n Delta Depth of Grout Seal / Type of Grout �r�Me� <br /> I I Irrigation Apptos. Depth 1 I Eastern Su5t^aee Seal Inslalird by G /ZlrrCfw <br /> Repair Work Done L) Type of PumpH.P, _ Aj/ State Work Done Y N <br /> Well Destruction D Well Diameter ..; SeL1n6 liatcrial 1 Depth U i <br /> Depth =:�S Fr tiller l4ater1al i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADOtTION I DESTRUCTION I I (No sepirc system wrnriteo if public sower is <br /> available within 21DO leet.l <br /> Installation %*ill serve: Residence _ Commercial___,^ Other <br /> Number of i"ng units: Number of bWrooms <br /> Character of soil to s depth of 3 feet: Water lobo oapth <br /> SEPTIC TANK G Type/Mfg CapacnY No. Compartmenls <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Wo11 Founomion Property Line <br /> LEACHING LINE D, No. E Length of lines 'Total length/size <br /> FILTER BED 0 Distanca to nearest: Well Foundation Progeny Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L' Distance to nearest. WeG Founoauon Propene Lina <br /> D:SPOSAL PONDS — <br /> I hereby ClondY that I have prepare{' this appiicat,on and that the worn will br oOne in accordance with Sart Joaov;n county orornances, state laws, and <br /> rues and rrgutations of Into San Joaquin County <br /> home Owner 0' liCens•ed •pans s Lignarure Cienrfrer the foliowrnp "I canny that in the pertormence 0' the work for which this permit is issued. I shall not <br /> arnplOy any person in such manMr as 10 lKcorne aubrecl 10 workman s compensJtion Laws of Cahtornia .. COnifector's hiring or sub contracllng s+pnstuie <br /> C41114401 !ha tOlbwinC 1 Canity that in trw por ormanCa of the wort for v^ich this permil is 1"uec, I Ghali employ petsonl svblecI io workman's comp*nLa <br /> tion taws of Califotnta .. <br /> Th* appiw_an; must calf loi a1' taQUW&C MLOOCOOnl. Comprete Orawrng on reverac sicto <br /> 5 — /-,- / ( 7� Tote G!/LYC� C'7 60 LC G / r Date' <br /> FO DEPARTMENT USE ONLY <br /> Applitatron ACC Date Area `} <br /> e01eC b? <br /> Pr, a Grout fnlp.ttron by Date <br /> Fins: inspection bt Data <br />,*AoOrtional Commtonls <br /> AppIIcnn: krturr. a;: ct;"�� t 5ar ?ouvu:r. Crura+ f'ut::c I I U L 5+•r�ltr: <br /> En t•:rpnvehLk' he 6,1 LI, Prrr. t `r r, c+•` <br /> E S.5 h Skn J0h0Vln, P C- kna 200' Sten, CA 952(i1 <br /> rLE I AmO,)P,' DUE �.MDUr:l REW-7E>^ CASH i RCC[IvE� B• I DATE t r'Ihs1ll Aro <br /> INFO <br /> ti+ tt-Ze I i !J i I <br />