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`we APPLICATION FOR PERMIT Noose SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HRALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EMIT MIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin Co+mt7 fpr a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules at+d Regulations or Ban Joaquin County Public Health Services. Job Address -/'fir A/ E! l)orae1n Strcc/ City -fDe-k4-cj Lot Size/Acreage -'aesTi z -z.00ff: Coilr 0�+�• �u �► Walkcr_ Owner's Name _e-•H• Wb,, Address Stac.Kkh, A 95ylY Phone 209 NGS-SOop 2825 �asf Myr t/G ��• _.-._ _ Contractor c /0ra--,4&n Ve- Address Siwe-k4s-i. CA 9S2cs License No. SI22(oil✓ Phone =4 4-9-g TYPE OF WELL/PUMP: NEW WELL fcPcr WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or Service Yell ❑ PUMP INSTALLATION ❑ 2-HW,trrtr9 .SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell- DISTANCE TO NEAREST: SEPTIC TANKN/k SEWER LINES 75 a DISPOSAL FLU. PROP. LINE FOUNDATION "8G AGRICULTURE WELL ==41J=A= OTHER WELL �.,,L�,r PITS/SUMPS Y" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation a Dia. at Wen Caskip 04 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PvC. Specifications VI Public Other "o-P '°r (Q Delta Depth of Grout Seal 0-23{} n'un Type 16. of Grout Nat 6.1.1* 1 M ran�tchirg 1 I Irrigation _Approx. Dept I I Eastern Surface Seal Installed by Repair Work Done O Type of Pump H.P. State Work Done _ Wen Destruction ❑ Well Diameter Sealing Material i Depth &nkan,fc- z 3-zc,f 1 _ 14c..,5) - Depth (N 33.v USO M-11 Filler Material i Depth Alat Climcnt 0-23 14 t!»roir-,) - -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I 1 (No septic sYstsm permitted if public sewer.st- ,V/A available within 200 feet.) Installation will serve: Residence— Commercial_ Other - -- -- ----- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Wen Foundation Property Line LEACHING LINE 0 No. dr Length of lines Total length/sae _ FILTER BED N/,4 ❑ Distanca to nearest: Watt Foundation Property Line SEEPAGE PITS l I Depth Sire Number SUMPS A11 A Ll Distance to nearest: Well Foundation Property tine _ DISPOSAL PONDS p I hereby certify that 1 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 County Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this permit is issued,I shoo not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sutscontractiog signature certifies the following:"I certify that in the perlorawnce of the work for which this permit is issued,l shall employ persons subject to workman's compsnsa- tan laws of California." The applicant t call f required inswtions. Complete drawing on reverse side. I!p mak. � Rf�t� Sim Ncuti a ,d well Signed rrW.Sa.,�-or (iro43+s+ +(�vtS�rvcito.. f��r.c� . • ate. - - �---- F EP ENT USE ONLY Application Accepted by Data /w `� Area 33 Pk or Grout Inspection by Date Final Inspection by Date Additional Commence: Applicant - Return all copies to: Son Joaquin County Public Health Services, latvironmental Health Perait/Services 1601 2- Haselten Ave., P 0 Box 2009, Stockton. CA 95201 CK A FEE INFO AMOUNT DUE AMOUNT REMITTEO CQAS`H RECEIVED 3Y DATE /SPERMIT'NO. . rM1}NIr1N.,��H .t�c7 { 6�•'y L // �_ �/ //7-?8 EM 147/