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lti r APPLICATION FOR PERMIT VV 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOA UIN PHONE — i� Q , N (209)468 3420 it P O BOX 20090 STOCKTON, CA 95201 i PERMIT k"IRTsS 1 YEAR FROM DATE ISSUED Complete in Triplicate) 1Q.�� i Application ib hereby slede to Safi Joaquin County for a permit to construct end/or install the vork herein Aescrlbed. This application is shade in eoe�lianee with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Pegulatione of Sari Joaquin County Public Health Services. y r I Job Address City Lot Size/Acreage .4i l{./t/ i Owner's Name I«y►mow ,"`L,&A,IJ Address Za 2 Chi S(_ra/de.) Phone 7 �LJ /�3�LJ ✓r 75551 Phone ConlratttN -Address License Nb. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT (-1 DESTRUCTION Ll Out of Service Well Cl I�p PUMP iNSTALLAT ONO SYSTEM RE 91R 0 OTHER O Monitoring bell n I DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES DISPOSAL FLD._� PROP. LINE 3V FOUNDATION AGRICULTURE WELL OTHER Wtl.Lmff� PITS/SUMPS s INTENDED USi TYPE OF WELL OA06LEM AREA CONSTRUCTION SPECIFICATION O Industrial ii Cl Open Bottom O Manteca Dia. of Well Exceva 'on Dib. of Well Casing ,I Domestic/PrI44 �(Gravel Pack D Tracy Type of Casing_ C Specifications V ('I Public 1-1 Oil ji n Delta Depth of Grout Seal Type of Grout. fEt/ I I Irrigation /ffApptox. Depth I I Eastern Surface Seal installed by 'm�u 1 )A Repair Work Done U I Typi of Pump _T H.P. cr,•o tivn•a bone \ Win DsstwetAh j 0 , Wall bibrnatii _ Sealing *terial a Depth 1 Depth tiller fttttekil IF Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is i available within 200 feet.) ° Installation will slirv : Reiidenci_ C6mmercibl_ Other af. E Numbs/tai"69,6616'. Number of*iooti i Cfiaractef of Iloff iffi depth of 3 test: Water table depth C SEPTIC TANK 0 Typo/Mfg Capacity No. Compartments J\ PKG. TAEATMENT;10LT.❑ Method of Disposal ^, ...., t bistatibe to nearest: Well .. Foundation Property Ltris� , ,- ' L7 No. S Length of Ifneb Total length/sizeLEACAINO LINE f F,ITO aro n bistanca to narireat:'• Well Fdundstion Zr Property Ltlllae SWAdt PITS 1 11 Depth Sirs Number SUMP$ LI Distance to dearest: Wall Foundation ' ' Propbrty Utii u. on -:DI§POSAL PONDS 0 s 1 hereby certify that II havtl prepfred this Ilpplicatloh and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rubs and rioulailion1i of,thi Sin Joaquin County Homs owner iii fieiAsrid agent's sfgnitura certifies the following: "I certify that in the derformance of the work for which this permit is issued. I than not employ any parson ifs such Manner as to beeomb subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 w6rkman's compensa- tion laws of CNlftirrla." The appliEant stall/f/or�Nl,�required ns actions. Complete drawing on reverse si e. / G Signed ✓ AJI r ' ' 8 Title: _ KLF��A Date: �! c3�E✓)' � !. FOR DEPARTMENT USE ONLY r Application Aci;iptW by bate !Lh° A?—_ Area Ph or Grout Inspection by Date /- Final Inspection by� Data 3 3 Additional CoMm4nt��: C4`� ?�D Loa - Heturn all copies to: San Joaquin County,Public Health se:rvicett lkoviConmental Health Permit/Services 441E N San Joaquin, P O Box 20o9i Stkn, CA 95201 f FEE j-AM0jUNTUE AM OUNT REMITTED DK RE EIVED 0Y O TE PERMIT'NO. IN . EN IS•Is It1tiV.r�s 61 ,� / / EH 14.28 /xo i)