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V. f.PPLICATION FOR PERMIT {. t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ 1601 E. HAZELTON AVE., PHONE (209)468-3420 P U BOE 2009, STOCKTON, CA 95201 i �'". . PERMIT EXPIRES 1 YEAR FROM DATE ISSUfiD (Complete it Triplicate) Application Se bereby sudgto sesn Joaqvith la County for . permit to ce No. 54 nand 1 62 siV1 the VorkRules hereto deatlo.s . This x p application 1a Pude In ealth Sere vete eav.lopnln Couatr Ordinance go. 5by end 1062 and the Rules and PeguLtioga on Ban l Joaquin County Public Health 8ervlcee.p /I f 4 Y , Job Addrass 770 r OJ`I �` 0'6 621lid- C,,V Y c. � las Blse/Acreage �•-1 �<cfe Ik y 6,c 4376 I Ownsr.Num. LpM04ny A AddressN=vY kr.. T% 77L10-4386 Plwn. 7f3 6SG- IB 'I rr 5`1.73 Frit-)crX IR Rd Cenhactor�.L�C{� {�dTMA+.I)rd�iw, Address RAnrC. F..,�,r< CA 95G7c License Nc. T4�L 7mene�41C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ rut or Berner Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C) OTHER ❑ B 1bn1tor3ng Yellf DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.__ PROP.LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , li n Industrial ❑Open Bosom ❑Manta<a Ob,of Wetl Essvltbn Ola of Wetl fa<inp Domas&/Priwu 17 Gra"Peck ❑Tracy Type of Casing pYL Spe-if"tions I Public Il Diner Dolls Dent of Grout Seal 10 Type of Groul Al:atMwu�.n�C I Iuylltron Awns.Depth 1 1 Eastern Sudaee SSW Installed by Tr[MI� 4/.bn•hn.l+- J Repair Work Dons ❑ Type of Pump H.P. State Work Done_ O W. Destruction ❑ Wall Diameter Beaune;wtrri.l a Depth Well . L Depth suer bsterlal A Depth L/1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION 1 I INo sepirc a"% per."add pubkc sees,b 7 - avis"pe within 200 falll .. r r Installetbn will asM: Rasidenc._ Commercial_ Other f Number of 4Vmg unit.: Number of bedrooms - - - , Character of NOM to A depth of J fast: Water ubla depth SEPTIC TANK ❑ Type/Mfg Caws y No.Compartmenn PKG.TREATMENT PLT.❑- Method of Disposal - Distance to nearest: Well Foundation PropeM Lira ! i LEACHING LINE ❑ No.6 Length of lines Total length/sue FILTER BED ❑, Distance to nearest: Wall Foundation Property Line SEEPAGE PITS I I Depth Sin Number � SUMPS LI Distance to nasnar W W FourWation Property Line 1�1 .DISPOSAL PONDS ❑'- lm I hereby certify that I have pared this application aha that the work will he dorsi In accordance with San Joaquin county 01.ultras,silt.laws,and rubs dmf regulations of the San Joaquin County Nome owner or licensed epanr':signature nnilbe 1M fotlowing;"I unify that In the pdorrhancs of the work for which thio permt is bawd.I ehatl not ampW any parson in such manner as to becomS Wbiact to workman's compensation Laws of California."Contractors hiring or suGcontracting rgnature j candle the fol owing:"I urtiH roar in tha laedormence of the work for which this permll N issued.I shall employ persons sublact to workman's compaoas a tion laws of Calllmm:' The apWkant I//sl/uq far W/lrpwraddlnapactbns.Complete dowing on rewras side. .Signed% TIM: Date: 6e vir<nnrd U Ir OR DEPARTMENT UBE ONLY > L aAp4Catbn Accapted by Date J Area rF+ sty T PR or Grout Inspection bOlt y e 8 Z Final Impaction by Date a- Additional Commenu: •Appllcaet — Return sll'coples for San Joaquin County Public Health n Services, Pavlruneental Health Percelt/B.rrieee 4 - 1601 L. E.taltw A,4.. P 0 Box 2009, Stockton, CA 95201 sEE AMOUNT OUE AMOUNT REMITTED CAS1. RECEIVED By DATE PERMIT NO. Ns0 fX I>2.IREy.I vire -2/l07 fX lei I 15-22