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w. h APPLICATION j SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ,HEAT T ,DIVISION K 445 N I SAN JOAQUIN, PHONE''„(209)468-3420 P O BO% 2009, STOCKTON, CA 95201 3 k PERMIT EXPIRES l MR -FROM ISSUED (Complete in Triplicate) Application Is hereby made.to San Joaquin County for a Per to construct and/or install the vork herein described. This / application is made in compliance vith San Joaquin County Ordinance fro. 549 and 1862 and the Rules and Regulations of San !! Joaquin County Public Health Services. 1 Job Address 3g2_5 /ACY 9OULIEVAAA City Qi Lot Size/Acreage- Owner's Name A2GU P2or�uc�S co", Address E' O. evy SSIt Sq,a Mort E-p CA 4wS94 Phone gISl`S7t- ?4 S,( Contractor WAY+it: MLUPIG CO. Address (>A.time lZL, LWcow, cA TE08 License No, 374141s Phone 9t(- 445-74Y5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER )iZMonitoring Well p� 51K SOIL,, &V9_sk) 5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE /D FOUNDATION (S` AGRICULTURE WELL OTHER WELL lOr PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El industrial O Open Bottom ❑ Manteca Dia. of Well Excavation a` Dia. of Well Casing n Domestic/Private ❑ Gravel Pack CKTracy Type of Casing_ Specifications 1"I Public o Other-t3a4,36 n Delta Depth of Grout Seal S` Type of Grout CCHOXIT I I Irrigationj S.Approx: Depth I I Eastern Surface Seal Installed by --- - Repair Work Done 0 Type of Pumpt H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other fi Number of living units: Number of bedroom_ s Character of soil to a depth of 3 feet: Water table depth ]]] SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of Eines Total length/size FILTER BED CI Distance tc nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Sue Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin ICounty Home owner or licensed agent's signature certifies the following: "Ii certify that in the performance of the work for which this perrnit is issued, I shall not am pby 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 fotlowing:."l cartify that in the pertom-once of the work for which this permit is issued,I shall employ pentons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete'drawing on reverse side. Signed X. ✓ Title: /°Wiz? G0Z"61s% Date: yl�2I 3 FOR DEPARTMENT USE ONLY / Application Accepted by Date Area C�� PH or Grout Irtspection by r Date 0 Final Inspection by Date i - l / Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE NFO AMOUNT DVE iii# AMOUNT REMITTED CASK RECEIVED BY DATE PERMt-1NO. UUU Eli 1}2,iREV.s i n 51 @— C J U `r�� [ ,3 a EH 14.26 ## Ll (V t a