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it, APPLICATION FOR PE"IT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL JJEALTH DIVISION <br /> 44 180x p'0 BOX 2009, STOCKTON, CA 95201/� I <br /> P�sabi. �c , y � 'ttQ;►I SiEp <br /> (Complete in Triplicate) <br /> Thi <br /> Applicatics, is tion is hrAde Ir, C0 pllariCe withuSApjoequlnocountyrmit to O dlnsttcerstruct No. 549sondo1862 u:dlthe Rules herein <br /> Reguls'longdaf San <br /> ayylica <br /> Joaquin County Public Health services. <br /> Job Address <br /> 17750 East Hi hwa City �Ynr•ktnn hot. Site/Acreage <br /> Arnold Souza17750 Cast Hi W Phone – – <br /> Owner's Name <br /> Address <br /> ConttactorCach^__ e Creek Drillin AdOress <br /> P-0 R x 99� tho.Dsil.anc�License Na,.,51LL�b3-----Pt,onyI:- <br /> Cache - - <br /> WELL REPLACEMENT 0 DESTRUCTION Out of getwice ell Q <br /> ell <br /> TYPE Of WELL/PUMP: NEW WELL ❑ OTHER ) f }tgiyo�'infl K <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0, 8r (SLGSEWER LINES DISPOSAL FLD. PR • L N <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION Tom-- AGRICULTURE WELL QTKER WILL�.�-- <br /> �r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing / <br /> U Open Bottom 0 Maniacs Dia. of Well Excavation <br /> Cl Industrial Specifications <br /> 1'.! Domasuc/Prlvate Cl Gravel Pack 0 Tracy Type o} Caning_ <br /> I'l PUblic L; Other <br /> f 1 otitis Depth of Grout $eal Type o} Gron7p,,bl <br /> I I Irrigation -- Approx. Depth l I Eastern Surface Gaul Installed Dy is �N ork Done _ v <br /> Repair Work Done 7 Type of Pump _ H P JJSacK cement <br /> Sealit'sS ldateritsl i Dayth Wall Destruction D Wtil Diameter r.� T111er Xstetrial i depth Depth 1 pTYPE Qf SEPTIC WORK NEW ifM!STALLATtON 1 I REPAIR/ADDITION 1 I DESTRUCTION I I evailb�eciwethi�^200 leetrueinstatladon will sarve: Residence J CornmarCisl Other r---- <br /> Number of living units: Number of bedrooms �- Water table depth <br /> Character of soil to a depth of 3 test: No. CompaRment3 <br /> SEPTIC TANK D Typo/Mfg CaPatity�...�-- <br /> Method 01 Disposal <br /> PKG`. TREATMENT PLT. MPr ort Line <br /> Distance to nearest: Well Foundation oP y <br /> LEACHING LINE 0 No. d Length of linos <br /> Total lenplh/size <br /> FILTER BED I Distance to nearest: Well Foundation . — Property Line - <br /> Number <br /> SEEPAGE PITS 11 Depth hue "' pro�ny Lina <br /> SUMPS CI Distance to nearesr: Well Foundation .,^�� <br /> DISPOSAL PONOS n <br /> 1 hereby comity that I have prepared this application and that the work voll be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and raoulatians of Ina San Joaquin County <br /> Home owner Or licensed agant's signature certifies the following: ,I comity that in the performance of she work for which this permit is issued, I she I not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sutl contracting signature <br /> camifiee the foifowing: "I certify that In the performance of the work for which this permit is issued, I shall amp Oy persons subject to workman's compensa. <br /> tioA laws of Cslilornts-" <br /> The opplica u II for all required inspections- Complete drawing on reverse side. 419/90 <br /> TiUs; President Date: <br /> Signed x B <br /> I /�_►/D l ( FOR DEPaRT�+1ENT USE ONLY <br /> Mar �� Dale - Area <br /> Application Accepted by Dot=7 �0 <br /> Final InspeCtloY <br /> � <br /> Pit or Grout Inspection by Dste.� � � b <br /> 01* <br /> s <br /> s- Additional Comments: =-52�4 <br /> Applicant Return all copies to: San Joaquia County Public Health r1,� C1LhOl�ii 6J7GYe?rl�c/ LvG� ��t <br /> Services, Environmental Reelth pertait/Services d <br /> 1601 E. Rate Ave„ p 0 Box 2009. Stockton, CA 95201 <br /> 9 <br /> F15 ItECV40 by GATE PERMIT No. <br /> AMO NT A7mODUN1T FtEWTT60 CASH <br /> t15 G n <br /> IV qr <br /> EM.17•jItRCV,Iipisi <br />