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`✓F e c-n vA1 f -APPLICATION I " Ex Pc,r,It4-rr ate/ ^��• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t a x s- E M r R T G c S r-• ENVIRONMENTAL HEALTH DIVISION ruLJr 445 N SAN JOAQUIN PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 T c f r 8 7-12— PERMIT_EXPIRES 1 YEAR FROM DATE ISSUED �J (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services C_ r1 �, _ Job Address -.S �J �r !1 ro 97-2 en— �r City_T114-C, Lot Size/Acreage �• �t �s S M l- 2-01- S-J A - OWner a Name .��r� C►tf4r,�/Zc!KfEi✓ Address _s�^/O/2 h� Gi} `333 3"(J Phone EI/�x T�Gr►Noc.uG-r Cf LG 9 A+ov.vr ,ftr+RMVNRO� 40X'5138_ Contractor 2"fG• Address 4101 (vt/ 5r-vi-r5 V4c-t,0,r,CIL License No rY'r4CZ Phone 2-Sr/l TYPE OF WELL/PUMP NEW WELL ❑ WELL REP }10EMENT n DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well C] I DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ u 0 industrial O Open Bottom ❑ Manteca Drs of Well Excavation -"' fy rr Dia of Well Casing k -Ikmomestocilrrvat ❑ Gravel Pack racy Type of Casing- Pyr- Specifications G�f'b✓(C G �'i I 1 Public _ ether (-1 Delta` Depth of Grout Seal Type of Grout e/e rr CA-me I I I IrtrOation _Approx Depth I i Eastern Surface Seat Installed by SPE Gr& E)ISPW/t�11�v✓,.,, Repair Work Done f] lType of Pump H P State Work Done _ Well Destruction ❑ Well Diameter ft t Sealing Material 5 Depth A/e,*r 4-e," Depth Z LFiller Material 8 Depth MU�/i ErL� Y !J f�� S'��_� -L TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I t DESTRUCTION I I (No septic system permitted if public sower Is available within 200 feet I I&nstallation will serve Residence— Commercial— Other Number of living unite Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT 0 Method of Disposal `1 Distance to nearest Well Foundation Property Line I LEACHING LINE C1 No 6 Length of lines Total length/size FILTER BED 0 Distance to nearest Well Foundation Property Line SEEPAGE PITb 11 Depth — I_i _Sire Number SUMPS LI _Distance to nearest Well Foundation Property Line I 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 taws and rules and regulations of the San Joaquin County Home ovyner at licensed agent's signature certifies the following "I certify that in the performance of the work for which this permit is issued, 1 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 issued, I shall employ persons subject to workman s compensa tion taws of California ' The applica mus call for all required Inspa trona Complete drawing on reverse side Signed }�X i Title � 2z^ Date 9 re c, dt'� r�PARTI4AENffTGGUSE ONLY�`d�tsi Application Accepted by Date Area Awri Pit or Grout Inspection b" Date Final Inspection by Date I ditlonal Comments Applicant -0 Returnr..,allt Vpies f!o San Joaquin County Public Health Services Environmental Health Permit/Services L� k 445 N San Joaquin, P O Box 2009, Stkn, CA 85201 ;Z1.rEE CK 11 s AMMO AMOUNTyD�UE AMOUNT REMITTED CASH RECEIVED BY OATS PERMIT NO 9 EN1 32,1011lV i/nslJiv 1) V �� •� •�_O / EM 14 28 V