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rAPPLICATION FOR PERMIT �efr SAN JO,AQUIN COUNTY PUBLIC HEALTR SERVICES _ ENVIRONMENTAL ILEALTH DIVISION �n.+I err;„�wells Sereee�a J4415-Jif San Soo WjPHON n p•O BO% 2009, STOCKTONE CA 85241-8420 Crohn r s9•I� ?at•ir3r�!u' ,,..rm c�onvnt+c t YNAR-FROM DATE IUM (Complete in Triplicate) Application is hereby made•to San Joaquin County for a permit to construct and/or install the York herein described. This applicatiba is Cade SA ecvpilanae with San Joaquin County Ordinance No. 5ti9 and 1662 and the Rules and ReSWatIOns of $an Joaquin County Public, Health Services. yll Job Address !t7 e 150 �A f/ �— City,S-fall !OF Lot Si telAcrenge -9 hone C • "7-G 3o ! ! Address ` {S�rC 1{S (3Iv�Sin eon de— hone l pwner's Nama 1 ContractarWG r live Addres3 F 44 1 LIE: No.lrr7 S_y979phone 'mss ' TYPE OF WELLIPUMP: NEW WELL E3WELL REPLACEMENT DESTRUCTION ❑Out of service hell ❑ / THER LS / MniurittfT Yal]a/ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑B�ra7t 4 Ole � c tayrr rxvfctrsr + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.LINE `!r 60) FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS iso t :•!inoustruf ❑Open Bottom ❑ Manteca Dim.of Well Excavation��_ Dia.al Weff Coring f 1 OamuuCrPuwte l ertavet Pack C Tracv Tvps of Cas+ng��tde/r A/O�V� Spat hcahans +w .fir "i Pubbc it other Il Della Depth of Grout SealOr Aj. 5alt"p{. Type of GtauU�N't�r ' I I Itr,Oation Approx. 04pin I I Eastern Surface Sedl installed by e: >` rl fir Repsit Work Done L] Type of Pump H.P. Stats Waft Dart,1='g — well Destruction ❑ Well Diameter Senila8 Material 1, Deptn 41if d Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION I i DESTRUCTION I I Mo sapnC sysrem parmivad it ptsbba sawer is available w+tndn 200 lest.I _r Installation vAil serve: Resident[,— Commerctel— Other '-' Number of living units:— Number of bedrooms Character of see to a depth of 3 beet: Water retire depth SEPTIC TANK ❑ TypetMfg --- - Capacity No.Compenments PKG.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Wag Foundation Property Line LEACHING LINE 0 No.h Length o{lines _• Total lengtnlsue FILTER BED ❑ Distance to nearest: Well Foundation Prepsny Line Ly SEEPAGE PITS I I Depth —Site Number SUMPS LI Distance to nearest: Waif Foundsiton Property Line DISPOSAL PONDS ❑ i I hereby Cendy that t have pteparad Chit application end that the waft will be done in accordance with San Joaquin county ordinances,stats Laws,and f- rulas and regulations of the Son Joaquin CountY Hams Owner or kcrnsed agent's signature candelas the following: y that in the parmfru "I Candlarence of the work for which this part is mued.I shit)not smp,0v any person in such manner as to becoms tublect to workman's compensation laws of Ca1{Iorn+a.”Contractor's Mang or sub-contracting signature candies the Iollawing:"I certify that in tete performance of ins work far winch this permit is issued,t small amplOy Parsons sunpa to wOrkreun's campsites- iion laws of California." pt, '. L" The applicant use CSIVI Of all required inspectlO Complete drawing on,reverse stda. Signed xs, _ Tale;��•!/�c�G7' lYIL�r24�i�911 1 ' -- Date: .AL I �9a FOR DEPARTMENT USE ONLY Application Acuptsd by Data 'I' Arms ,_----- --....-..---`._=--PitOrGrou[ImpsctidnbyDats......._.._._......... .... ...Final Inspection by .Date i I dditionat Comments: Applicant - Return. all copies to: Sao Joaquin CouatT Public Health 1 3rvieam. Enviracstsatrl Health Perrot/Service■ l 16o1 E. Hateltoo Ave.. P 0 Box 2009, Stockton, CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED C SN RECEIYEO BY GATE PERMIT NO. INFO