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!—Z APPLICATION SAN JOAQUIN COUNTY PUBLIC K ENVIRONMENTAL HEALTH ] 445 N SAN JOAQUIN, PHONE ( P O BOX 2009, STOCKTON; �J ALTH SERVICES IVIS �ION :09) 468--3420 CA 95201 (Complete in Triplicate) Application is here made to San Joaquin Count for ��, !i Pp by 4 Y permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5§,9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. wA I!!i Job Address AIA40R AART 1238 EAST Ali_f) IE AYE City ihl Lot Size/Acreage _130. -y IZOr SRAZOS ASSN A-AA14AGI32 YyIeW II! Owner's Name !' O CRC Er4ViQo#4W1EMT-AL Address So[ C.omrnspce iST• SJtTE i45o Phone (81"1} 8`IOy2Z�5 I RECEIVED BY jl eT OQT-R, .x 'T 0 oZ WEST t ESTI N/6ZMAY Address 3233 Fi TZOEIZALfl 511 License No. 55y979 ��7 phone Ib'b3$"72�b TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [I DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION C7 SYSTEM REPAIR 10 OTHER X ,,,Monitorin, l�5 C7 DISTANCE TO NEAREST: SEPTIC TANK "— SEWER LINES DISPOSAL FLD. PROP, LINE 2-)S ' FOUNDATION AGRICULTURE WELL IIOTHERJWELL — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r3 —1►tc.H Dia. of Well Casing N At 1-1 Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_ N Specifications WA I'] Public El Other n Delta Depth of Grout Seal' ToiAL Type of Grout NERT ckIrfeir I I Irrigation Approx. Depth f I Eastern Surface Seat Installed by EfsT HAZ.NIRT Repair Work Done U Type of Pump H. P. iI StatelWork Dana Well Destruction ❑ Well Diameter Sealing Material b Depth i Qmly r / gi wbN rT4r C>77+tt. t —p7Ft SC1L •9RMPL 440 )f Depth $s 86$,S Filler Material 8 Depth 11 �� ^ TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRIADDITION t I DESTRUCTION I l ilNo septic system permitted if public sewer is �N, j1. available within 200 feet.} Installation will serve: Residence— Commercial _ Other i Number of Ii ' units: Number of bedrooms Character of soil to a e feet: I ater table depth SEPTIC TANK © Type/Mfg PKG. TREATMENT PLT. ❑ Capacity �l Compartments •I� Distance to nearest: Well .�� _ n�o�t Fou ;! �I LEACHING LINE ❑ No. & Length o s �jT�Ai1� ize FILTER BED {�� C] Distanc nearest: Well Foundation Il a 0 SEEPAGE PITS Depth Size mbai d.MuN D1v�Sl SUMPS Ll Distance to nearest: Well Foundation Property Line )ISPOSA NDS ❑ Ips i hereby certify that I have prepared this application and that the work will be done in accortlance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County I! Home owner or licensed agent's signature certifies the following; "I certify that in the performance ofI the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issIued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must all Nor all tire inspections. Complete drawing on reverse side. 11 Signed l3 Title: ZEN.10R GEEDLOCoi3�. 10—q 4 Date: 1\J.�� FOR D PARTMENT USE ONLY Application Accepted by v, 'Date es,— 1(7 f Area i Pit or Grout Inspection byDate Final Inspection by I' Date Additional Comments: Applicant -- Return all copies to: San Joaquin County Public HealthhServices �� I Environmental Health Permit/Services !I. ` 445 N San Joaquin, P 0 Box 2009,,11Stkn,;Il ICA 95201 M INFO • EH 13-24 {AEv. i i n 51 EH t4 -a6 AMOUNT DUE AMOUNT REMITTED CASH I RECEIVED BY jl DATE PERMIT'NO- `o 0Z) ILI J° r