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ADPL I CAT1 ON FOR PERMIT � �T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 4 P 0 BOX 2009 , ; STOCKTON , CA 95201 (209) 468--3447 ' • YEAR FRQ9—DATE ISSUED (Complete in Triplicate) A,p11c•tlon in hereby mAde to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Sun Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San 4 Joaquin County Public Health Services. / Job Address J�oD EAT SFZE-M0/J7— `�r City STOGft-TD Lot Site/Acremge L.)ES T / Owner's Name )40P-- CAL— BG.VU1A10E- Address ZZ S70rJ — Bo/b. SA Phone f/�r- 3�L-ObOD KLEI�FELnErZ P Cont,acfor E t 11 ><�( L17LXT7o ddress QZ5 E. MYi�i L��i. License NoG��' FhonrZD (2- T'iPE OF WELLlPUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service well ❑ SOIL 13O 1Z ItJ� S PUMP INSTALLATION C3 SYSTEM REPAIR Cl OT}�W Monitoring Well CI DISTANCE TO NEAREST: SEPTIC TANK '# �O • SEWER LINES `{ 50 � DISPOSAL FLD.-t 5d PROP. LINE FOUNDATION ^ AGRICULTURE WELL SO OTHER WELL 1S • PITS/SUMPS 500`T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ? Industrial FJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j LI Domesticiptivete CI Gravel Pack L3 Tracy Type of Casing-.-- Specifications i_] Plrhlic Il Other ❑ Delta Depth of Grout Seal Type of Grout 71 Irrrljation ^_ Approx. Depth 0 Eastern Surfade Saul Installed by Pnpeir Work Done U Type of Pump H.P. Stasi ork Done �J V.N01 Destruction L) Well Diameter Sealing Material i Depth SAND CErt2 rfT eDwT' I r4141-X"1 ` %7, CWrL"ite,l Depth Filler Material i Depth �1r1 NBaY �C1JTVN17F— Z TiP4 4r= .OIL v TYPE OF SEPTIC WORK: NEW INSTALLATION [i REPAIR IADDITION C.1 DESTRUCTION Cl lNo septic system permitted if public sower is available within 200 feet.) Installstion will serve: Residence _ Commercial Other Number of living units: Number of bedrooms110 ` Character of soil to a depth of 3 feet: Water table depth SFPTiC TANK D Type/Mfg Capacity No. Compartments r,KG. TREATMENT PLT. [1 Method of Disposal Distance to nearest: Well Foundation Property Line - 1 LEACHING LINE C1 No. 6 Length of lines _ Total length/sire PAYMENT FILTER BED CI Distance to nearest: Well Foundation — Property Li ❑ I SEEPAGE PITS I I Depth Sire Number •I SUMPS Ll Distance to nearest: Well Foundation Pr0per%MgeA4Q4 4-C-0UNTY DISPOSAL PONDS ❑ PUBLIC H`AI T i -,Ui I I he,aby certify that I have prepared this application and that the work will be done in accotdance wit Y It NJA[r,WAtlRJr[ QSj!GtJ laws, and rules and regulations cf the San Joaquin County Home owner or licensed agent's signature certifies this following: "I certify that in the periormance of the work for which this permit is issued, I shall not ernproy any person in such manner as to become, subject to worhman't compensation laws of California." Contractor's hiring or sub-contracting signature corlifies the following: "I certify that in the petiormancs of rho work for which this permit is istued.I shall employ persons subject to workman's compensa. tion laws of California," The applicant;1nVst call for all AVlad inspections. Complete drawingon reverse side. S fined X ,•" Title: 1 7 :r Date: FOR DEPARTMENT USE ONLY I Application Accepted by + Disse Area fit no Grout Inspection by Date Final Inspection by Date Additlnnal Comments: I LJ W -. �AI';I1ce.nt - Return all coPles to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMEN'T'AL HEALTH DIVISION PERMIT/SERVICES �l 445 N SAN JOAQUIN. P O IIOX 2009, STOCKTON. CA 95201 FEE A►.P1UNT DUF AMOttNT nEWT-TED C K CrIVED BY DATE PERMIT NO. trfFO _ Sit rti t,:�,�Fv t.w7r P-)9.LJD 69• -