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5 {`r APPLICATION ;FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVIS ENVIRONMENTAL HEALTH DIVISION V P 07BOX 2009, STOCKTON, CA 95201 (209) 46$T 3447 21"1T :E%PIRE$ 1 YTsA_A�`�t�ld DATE ISSUTD F r� VEL) (Complete in Triplicate). =' t J� 1991 Application is hereby made to San Joaquin Count for: 4 SAN ��fiA( �Pijeprpibed. This 9 y permit to construct and/ inata�i application is made in compliance with San Joaquin County Ordinance No. 5+9 and &EA"R sip, _ ��`}�ppa of San Joaquin County Public Health Services. 3 t � 4r'T' ` ��44 n j rnL HL Al U, i Job Address 0v AST N T'U IN E R 0� AD City : Rik Lot Size/Acreage Owner's Name t4oal L 4 Address D L E Ai! CA ?hone V$ � (�vCMCCClLlC7i'Y� I Conlractor _s_r PA-J[MJET D!?CG. Address 1333 rj—UrAERALLicense No,-5.6-49 79 Phon ,F C 3F-7 76 TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM_ REPAIR ❑ OTHER ❑ Monitoring Well 1l�� €ccsJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES C 3—,.o 14 I,r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Industrial ❑ Open Bottom ❑ Manteca ` Dia. of Well Excavation_g~oIL/O�� Dia. of Well Casing 2:_ 50 Domestic( rivate 9 Gravel Pack ¢cl Trac �l . ,__... y Type of Casing_P i/L Specifications M Public I'1 Other ❑ Delta Depth of;Grout SealsS_ Type of Grout lKrF/FT CFMeiyT CJ Irrigation 2E Approx. Depth O Eestern Surface Saul Installed by WEST ftAJMd7 DIZIi-t4ovCP, Repair Work Done 0 Type of Pump H.PiState Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Piller Material i Depth r } TYPE OF SEPTIC WORK; NEW INSTALLATION IM REPAIR/ADOITION 0 iDESTRUCTION U 1No septic system permitted if public sawer is ' l available within 200 feet,) l Installation will serve: Residence._ Commercial_ Other � Number of living units: Number of bedrooms �{ Character of soil to a depth of 3 feet: I Water table depth T SEPTIC TANK p Type/MigCapacity No. Compartments Z PKG, TREATMENT PLT. Clu Method at Disposal Distance to nearest: Well ,r Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Wail Foundation . Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the,Nork will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following; ,'i certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workrrian's Compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required snaps, ns. Complete drawing on reverse.side. r Signed r, A-. Title: A0J',C7_ 'G Date: � i 1 I iA,)' FOR DEPARTMENT USE ONLY Application Accepted by ` Date Z~ Area Pit or Grout Inspection by Date 5 r�F�in11 inspection by Date 1 p Additional Comments: —LLIIW Applicant - Rat= all copies to: SAN JOAQUIN COUNTY UBLIC HEALTH S IC ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN; p 0 BOX 2009, STUCKTON,, CA 95201 INFO AMOUNT DUE AMOUNT FIEWTTED', a5H ECEIVED BY DATE PEHMITNO. ;/,fir �''',�� ., J/ EH 13.24 MVV.I/rs) J, ae-, EH :4.:a f �3- � -IiVIJU f }