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APPLICATION' FOR PERMIT SA"'ILIAQUIN COUNTY PUBLIC HEALTH .ICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 y�. PERMIT ESPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a parent to construct and/or install the vork. herein described. This application is made in compliance vith Ban Joaquin County Orrises No. 549 Lad 1862 and the Rules Lad Regulations of San Joaquin CountTTPublic HeealthServices. 4M Job Address � yaj-Lr , ` , n! 's" LZLIv� City Du m LOl Lot Si /Ace i Owner's Nan» Cold r '5'Pcr6 H C . Address G4W E• Of i11,,Awr^a4_- La"'S Phorw Z G -O po. Zc-'A 1b4+ CA 95[!1 C-57 Contractor W ESTEX Address r--1 License No. SS2198 Phone y 16 3 t�-f I TYPE OF WELL/PUMP� NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of $arYfee well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring hfel15 DISTANCE TO NEAREST: SEPTIC TANK ?W -Pl• SEWER LINESV� DISPOSAL FLD.OJA PROP. LINE1 e ii-• FOUNDATION 7Lb EE• AGRICULTURE WELL 15-ELff.10TMEA WELL-A!/,4— PITS/SUMPS A0 INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ,� _, Industrial ❑ Open Sattom ❑ Manteca Ois. of Well Excavation fa Oia. of WW Casing f".i Domestic/Private Gravel Pack ❑ Tracy Type of Ca" 4 r SJ"- 40 PVL Specifications I'1 Public 11 Other rl Delta Depth of Grout Seat38 'R Type of Groin I I Irrrpalton —Approx. Depth I I Eastom Sudcc Seal Installed by Repair Work Done ❑ Type of Pump f` r� M.P. Ste Work Derr Well Destruction ❑ Weil Oiarnster Sesl.Ln6 ala sial i 3O 'rL - w• „�e•ti -., Depth ^_, 60 -Pk. Tiller liatarui b Depth (jro..e.1 �� A.b. 3 'M'f S TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR IADDITION 1 1 DESTRUCTION 1 1 Ileo septic system permttW d public sewer n available within 200 feet.! Insnllatto it servo: Rasidsncs_ Commercial_ Other Number of living Number of bedroonns Character of soil to a death o We depth SEPTIC TANK ❑ Typo/Mfg Capacity No.CunWrvnsnts PKG. TREATMENT PLT. ❑ Method of Disposal Oistancs to nearest: Well n Property lana LEACHING LINE C1No. b length Tots h/sins FILTER BED ❑ Oista o nearost: Wed Foundation Props SEEPAGE PITS I I Depth Sumer e Nub SUMP LI Distance to nesrrast: Wall! Foundation Property Lute DK�POSAL ❑ I hereby csndv that 1 hew orsosteo this application and that ilia work wW be done in accordance with San Joaquin county oralnances. state laws, and rules and regulations of the San Joaquin County HOthe Owner or licensed agent's signature comfies the fodawl, : "I Canitv that in the padOrmance of the Work for which this permit is issued, I shelf not employ any person in such thornier as to INCOME Subtract tb workmen's cofnoransatton Laws of California.,*Contractofs noting or suo-contracting signature candies the following:"1 corbly that in trial pedormancs of the work for wntt:h this partret Is issued,1 shelf srrploY Persons subNct to workman's cothpranza• non Iowa of Cakfomis." Th apptic 4 for /W�f0 Complete drawing an reverse side. Jt y / v , 1 V� Ole r.24 � L2 1-4. Tied: R.C I Z/� Date: I FOR DEPARTMENT USE ONLY Application ACCeoted by Date Area Pit or Grout Inattsetion by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Eavir000anral Health Persit/Services 1601 S. Haultain Aye.. P 0 Hos 2009. Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASM RECEIVED BY DATE IERMIT'NO. INFO • elf 1]•Ir IAN.1/A!1 ' rN 14211