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APPLICATION FOR PERMIT -� SAN JOAQUIN COUNTY PUBLIC EEALTH SERVICES ENVIRONMENTALHEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERLTT EXPIRRS 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby mazle,to Sea Joaquin County for a parfait to construct and/or AGA) t7!- 300- 07 install the work herein described This application is made Sn ccsepllence with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San Joaquin County Public Health Services. r Job Addras�373 44A of Po«RR'OAn CitySt�K�r+Af Lot Site/Acreage JSACPES Owner's Name Nosey CRIEVI TAIL Address 2373 MAPtt0I P-o Phone 1464- 763J Conlraclor0Sl£RBERG t' S7EIA/ART-SwYAddress �,SZ'i 21vRO MXJ6<aTC License No.446fo-/yl Phone 7-5767 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT O DESTRUCTION O Out of Service Veil O PUMP INSTALLATION O SYSTEM REPAIR O OTHERMo Loring Well O /�', /&III s-b LES DISTANCE TO NEAREST: SEPTIC TANK 75 , SEWER LINES /JOn a DISPOSAL FLD.rI PROP. LINE S' FOUNDATION -IeL� AGRICULTURE WELL OTHER WELL_20� PITS/SUMPS GLonG INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F.1 Industrial O Open Bottom O Manteca Dia. of Well ExcavationOI Dia. of Well Casing N� N t<Domestic/private O Gravel Pack O Tracy Type of Casing NOA/C Specifications- IVAA O Public kT Other O Delta Depth of Grout Seal SORPA-CC Type of GfoutCmrCl 1�s litigation lq Approx. Depth O Eastern Surface Saul Installud by CO0T'2AC-rup-- Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material 6 Depth Depth 7111ar Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION C1 DESTRUCTION G (No septic system permitted it public suwer is available within 200 1041.1 Installation will arvc Residence _ Commercial_ Other Number of giving units: _ Number of bedrooms Character of soil to a depth of 7 last: SEPTIC TANK. _Water labia depth O Type/Mtg Capacity No. Companments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. 6 Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of IM San Joaquin County Home owner or licensed &gem's signature canities the following: "1 cenilY.that In the porlormance of Iho work 10, which this permit is issued, I shall not employ any person in such manner as to Docome subject to workman's compensation laws of California," Contractor's hiring of subcontracting signature canities the fallowing:"I Certify that in the performance of the work for which this permit is issued, I shall em Io tion laws of California;' D Y persons subject to workman's wmpenw• The applican mu all 1 4I fequir d inspeclions. Complete drawing on reveaa/sii_de, Signed �OYKu//U n.� Title: beta; LlvdLr 16,1 /FZ FOR DEPARTMENT USE ONLY / Appliutlon Accepted by ^.r,r a Dae Arae Pit or Grout Ipepeaion by - Date Final Inspection by Dete O ZS g / t \l) Additional Comments: �P✓5 Applicant - Return all copies to: SAN JOAQ IU N COUNTY PUBLIC HEALTH SERVICES aQL/ ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 2 / 445 N 9ANJOAQUIN, P 0 SOX 2009, STOCKTON, CA 05201 v �/d FEE 1,161:1 '111 DUE AMOVNT AEMITTED INF/D� q Q CASH REC EIVEO Y DATE PERMIT NO. „ U•lr II11Y.I,.er�ii S7 O9.