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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAY <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED. P 0 BOX 2009, STOCKTON, CA 95201 ED <br /> (209) 468--3447 JAN 19 1993 <br /> PERMIT EXPIRES I YEAR ?R09 PATE N JOAQUIN COUNTY <br /> (Complete in Triplicate) NViRONMFHEALTH <br /> A LTH SERVICES <br /> application is hereby made to San Joaquin County for a permit to construct and/or install the vork berci C6PY This <br /> ppllcatioa Ss made in cov:isliance vith Sari Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> lob Address <br /> �- {O 9 5,'AIA(Z) ?OsZ2 _--- CityS � <br /> TbC ,rj Lot 31se/Acreer,d{gc I e- <br /> '1 <br /> Owner I Name - Address l� f� �4 r?P. Address <-7C0A=1?d Phone 'Z 70 <br /> /� 2573 eIV4Z RC--A_a ,S3 _57G <br /> cntraclotl: 57 RB ER( ri <br /> i S7E .d i2f Address, MToonC5C_:4 Y,S T1 License N04,9!4-7o —Phone <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 out or Service Wall ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well ❑ <br /> _ Sala 6091IV66 <br /> [STANCE TO NEAREST SEPTIC TANK-264-0. SEWER LINES 2-60r DISPOSAL FLD L'4 PROP LINE 41:— <br /> FOUNDATION 15 r AGRICULTURE WELL M/A OTHER WELL N�� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,,,, <br /> Industrial ❑ Open Bottom ❑ Manteca Out of Weil Excavation 8' :i — Dia of Well Casing Gia <br /> DomesuclPnvate ❑ Gravel Pack 0 Tracy Type of Casing A119111 Speuircatrons <br /> C3 Public Oq Other ❑ Delta Dr-3;h of Grout Seat Suf LiGr^ -- Type of GroutGc�t flrYlt ,,t <br /> tlrr+Uaticn JL5_2 <br /> Approa Depth ❑ Eastern Surface Sed] Initalled by 160I"o r <br /> part Work Done ❑ Type of Pump /Y1A H P Stat@ Work Done <br /> Wail Destruction ❑ Well Diameter dVA _ Scaling Material i Depth <br /> Depth Filler Material L Depth <br /> F SEPTIC WORK NEW INSTALLATION Q REPAIRIADOITION Cl DESTRUCTION CI Wo septic system peernuted if public suwer is <br /> available within 200 lest I <br /> Installation will serve Residence ,_,,. Commercial— Other <br /> Number of living units Number of bedrooms <br /> Character of soli to a depth of 3 feet Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity_ No COmpanrnants <br />�KG TREATMENT PLT,❑ Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE ❑ No 3 Length of lines Total length/size <br /> ILTER BED n Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> UMPS Ll Distance to nearest Well Foundation Propony Unit, <br /> ISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accoroance with San Joaquin county ordinances state laws, and <br /> rules and regulations of the San Joaquin County <br /> tanrPT'I'O'y <br /> owner or licented agent's signature certifies the following I cantly that in the perlarmance of the work tot which this permit is issued, I shall not <br /> any person in such manner as to become subject to workmen's compansitoon laws of California Contractor s hiring or sub contracting signature <br /> ifies the following, "I canify that in the performance of the work for which this permit is issued, I shaft employ parsons subject to workman s compensa- <br /> tlon laws of Califoinla." <br /> heapplica2Accaptsd <br /> ca I f all to uved inspections Complete drawing on reverse side <br /> igned Title CO S Date TQ r 7 <br /> FOR DEPARTMENT <br />�pplieatlon by D&L Asez <br /> PIt out Inspection by Find Inspection by eta <br /> Iddalonal Comments. � ) <br /> 9plicaat - Return Lll coria, to. SAH JOAQUIN COUNTY PUBLIC HEALTH SLUVIChS (�(� <br /> ENYIRONUENTALSANJOA HEALTH DIVISION 20 P, STU/SSRYICCA <br />' <br /> 445 N SAN JOAQUIN, P 0 UOX 2006, 3TUCKTON, CA 952012 <br /> EEE <br /> [NFO AMOUNT DUE AMOUNT REMITTED CK AECEIiltO BY DATE PERMIT NO � <br /> rg � � CASH <br /> /�► �t�y�y <br />