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( J APPLICATION y/ �PEGT�LI/M SAN'�JOAQUIN COUNTY PUBLIC HEALTHQERVICES E F PI uR 41 lii^� t ✓G' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 zRz S E- MyRrLE 5rr P O BOX 2009, STOCKTON, CA 95201 Sr`oGF(v^% C A SSoLJ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ZDy I{LI - V YJL (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in wade in eoupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,l Job Address , 5 s 6. 117-1+. 5 r/L66 r" City_TAAr4-Y Lot Size/Acreage Irl hGII.ES TAA Lir- VA V b Kn/ r ISOS'1 C.}bLC OESTE, zoy- r5L - owner'sName D4&Xyl. �µA-ISIIT /SLC^Y Address S01/0IL9y G9 3' t 331-6 Phone -S-// E✓A7c TE GRr/vLdilESZAAC• 2.( 7 ndov✓r li(5iLMvNftOy 4y 4fag t38- �1 Contractor Address 4k'I0tf 5'COM / ) .Ey2 G9 License No. 'S}TGG z_ Phone 4wo 861 TYPE OF WELL/PUMP: NEW WELpgr- WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well �T DISTANCE TO NEAREST: SEPTIC TANK NR SEWER LINES 47* 60' DISPOSAL FLD. N9 PROP. LINE fir'/dvr/C Q,1 FOUNDATION AGRICULTURE WELL __�'f OTHER WELL---/—V"+ PITS/SUMPS !O�A ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excevatio�-UT— Dia. of Well Casing F Y<IfDomestit/ riv�es L) Gravel Pack flTtacy Type of Casing_.__f✓G_ Specifications -LLW/eLh I Public ROther IJ Delta Depth of Grout Seal � 6 _ Type of Grout */Ctr 4CatevJ' I I.Irrigation __,Approx. Depth I 1 Eastern Surface Seel Installed by Stec cit✓- E I<hGUIt Repair Work Done ❑ Type of Pump - H.P. State Work Done _ Well Destruction ❑ Well Diameter H a Sealing Material i Depth A16,t7' GE At C- ✓T' v 6 �t ' . ViSrMt�Y T_Yfi S.t--/o 8 /-LLr ' Depth ^' 22 Filler Material L Depth MU � TYPE OF SEPTIC WORK: NEW.INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is , available within 200 leetl Instillation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms , Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK Cl Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WellFoundation. Progeny Line LEACHING LINE ❑ No. g Length of lines __- Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire- Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' 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 County Home owner of licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shag 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 issued, I shall employ persons subject to workman's compensa tion laws of California." Thea �/rsJ pplican u t call for all required inspections. Complete drawing on reverse side. 9 / Signed %" title: —�"/ Date: jfOR_o-DIE PARTMENT USE ONLY cJLU�1 j n a yb a r •3�L�f L _Application Accepted by Dare l Pit or Grout Inspection by /'ftp/�'-<Q�L Date S T nal Inspection byDate Additional Comments: Applicant, - Return x1.1 copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �1� '� �., 44.5 N San Joaquin. P 0 Box 2009, Stkn, CA 95201 /A_ I/t141 INFO CAMOV NT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. • Ftat 4.]E(REV.rrn Si