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• APPLICATION POR PERMIT J l SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES ENVIRONMENTAL REALTH DIVISION P 0 130% 20091 STOCBTON/ CA 95201 (209) 488-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applleetibil it hereby lade to Bad JeA4uin County rot E pdralt to lonstruct and)or LnstAt1 the work herein described. This application 11 We ih oampllance with San Joaquin County Ordininca No. 549 and 1862 and the Rules and Regulations of San Joa4uie County Pub i Health ervieAl., I 9av 1Ue. WoskI11�� Jab Address �T CIF 5 City S"TOGIGTosJ Lot BSE!/Acrlag! "' 11-s AC-MF5 Owner's Nam! Poor 0-F 3-rocx-TVA Address 1-7-6I W. phone ace q 0Z46 ZOd-1 A014101.e I"OV5-Tlrtrlt- t_.Ay Contraclor l'�0EY�1 dfZIIA.IsJ(o Address i'r,..l taJ501 0IIE M 51 � S/J4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U Out of Service Well ❑ PUMP INSTALLATION 0 9V2TEM REPAIR C1 OTHIA ❑ Menisarine Mall K DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES VAtlt63 DISPOSAL PLO, PROP. LINE _ LST— FOUNDATION AGRICULTURE WELLMtaE OTHER WEl4yjt PITA/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (1 industrial 0 Open Bottom ❑ Manteca Olt. e1 Wolf E)(cevelion bit. of Well Casing Z 1Nrs4 U Domostie/Priv11► V Gravel Peck Cl Tgcy Type of Clling ScAI 4b WG Specilicationl 0 Public 1.1 Olhet 'A D6Ita Depth of Grout Seal Type of Grout CJ IfdUallon —Al moo. booth ❑ EatHirl Surficl Seel Installed by Repair Work Done U type of pump H.P. Suis Work Done _ Well Destruction ❑ Will DlamatAt Beilin5 lattrial i Depth Depth pillar material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION 0 INo septic system permined R public sower is available within 100 1661.1 InauK111en will esrv6: Resldli Camrhitelt)_ OthU Numbet of Bving units: _ Number of bedrooms Chi rectet dl lee to I depth of S lost: Weser table depth SEPTIC TANK ❑ Typa/Mat! Capdtity No. Compartmentl PK(). TREATMENT PLT.❑ Method of Disposal Dlalanee to nearest: Well foundation properly Lina LEACHING LINE ❑ No. A Length of Mad total leg it FILTER SEb ❑ Distance to nattiest: Weis Foundltlon —RECOMER— C SEEPAGE PITS 11 Depth —Size Numb r SUMPS LI Diallnco to holiest: WON Pbundotion SAN } DISPOSAL PONDS ❑ Uf Q 1PC HIAl PT,,IyL�IVI510N I htraby certify that I h6va praparod this epplicitlon Ind that the wotk will be dons In Acc nce with San Joaquin cbunty ordinances, state laws, and rules and regul/Ilona el thl Sin J611duld County Home Owner or 11COMld I0en1's Ilgnsturl cirlifita this following: "I certify that In the perlormence of the work lot which this permit Is issued, I shelf not employ any portion Ih such mahnif II to bift6rhA lubj4d to workman's combenatillon laws of California." Contraclor s hiring or sub contracting signature eM11161 the foAbwlnQ: "I tortify that In the pArlormine/61 the work lot which this permit Is issued, I shall employ persona subject to workman's compensa. tion law$ of ClllfomIll." The applicant mux.1�I0 11)r All to bred Inlp6ptlons. Complete drewlno on reverie aloe. Signed x J�/( Z-40? Tide: --mil °f- Gt-01c�6r Dole: 5I70h Z- E t SS6L F()q DEPARTMENt USE ONLY —7 r�11 Application Accepted by - ' X�` Dau ` "'V Area 3 U ✓H1 - 71t3(f+ Trr st t!s J7 ttlyr c�,A Pit or ()rout Inspection b / `_� ` ste��a3! 'l,-! Final Inapecllon by Yc Date a� 1 Additional Cc nNnte Applicant - Retitn in copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIV1610H PERMIT/SERVICES 446 N SAH JOAQUIN, P 0 BOR 2009, STOCKTON, CA 95201 1 FEE INFO jAMOUNT DUE �A+MOUNT Rfivirr 0 CqK �REECCEEI�VE_D By 7 DATE 1. 13 74'REV,11.,. _� W —6-0� lJi i ' CoG / [ .� l� d7r,LJ M t61e l