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l.01, .4,dAPPLICATION _, rode0" r �D �� t ,..arer�zi-SAN 1r6AQUIN COUNTY PUBLIC HEAL 1 CES 49 ng Code ex g-fi 4c"rreW ENVIRONMENTAL HEALTH DIVI —��. _ r� 445 N SAN JOAQUIN, PHONE (209 0 P 0 BOX 2009 STOC%TON, CA19 91 SAN JOAQUIN CO LTWI Y-PUBLIC IiE RES 1 YEAR FROM D E I'1�YSlflsB a 2 � `� ENTVVIRONyhriiEtEeNTTbA�L�Ha�E9A�LpTiiDiVISION (Complete in Triplicate Appli applle] fa�La�Z rSmpO.l�h Cunty for a permit to construct and/or install the vork herein described. This Joaquin County Qrdinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Count Public Health Services. County -sIe S SE iz• t /a uJe// 'few / Job Address �* E�CS-L r��.(. _ L City Lot Size/Acreage ,. ��/4(2L Owner's Na r to• Address /�Z�LL' ICr9. IN11lL7 fl!! I.�!/.l, Phone Contractor - • Address . 1'zs PC'L License No. Z e -3 Phone TYPE OF WELL/PUMP: 9NEW WELL X WELL REPLACEMENT ❑ - DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK nnnL SEWER LINES .50 r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS asp Cl Industrial �/❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 719F Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ Specifications /3: u 14 Public 11 Other Ll Delta Depth of Grout Seal ley Type of Grout .- I I Irrigation j(VApproa. Depth I I Eastern Surface Seal Installed by / G'CE"/tPR � ) Repair Work Done U Type of Pump H.P. State Work Done_ V Well Destruction ❑ Well Diameter Sealing Material a Depth 1'ta -l.ao 1 - h Filler Material i Depth I—A TYPE OF SEPTIC WO K: NEW INSTALLATION I I REPAIR/A UCTION I I (No septic system permitted it public sewer is RECEIVED available within 200 feet.) 1P Installation will serve: Residence_ Commercial_ Oth�ear��/ I� Number of living units: _ Number of bedrooms—_—MAY I 1 t994 Character of &all to a depth of 3 feat: SAN! '044—P, @91Jf T --- Water table depth SEPTIC TANK ❑ Type/Mfg PUBLIC HFGI TL SAE#V) Es No. Compartments PKG, TREATMENT PLT.❑ ENVIRONMENTAL HEALTH DIVISION Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 or licensed agent's signature certifies the following: "I certify that in the performance of 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 issued, I shall employ persons subject to workman's compensa- tion laws of Calif nis." The applifaot�qu t call for all required ' coons. Complete wing on rse / Signed / - -� Date: FOR EPA MENT USE ONLY r(l� Application Accepted by C Date Area Z 1 / PB or Grout Inspection by Yate Final Inspection by Data 7 ZI Q Ad itio7(`ZN o -n wwcE/ 76 (rt.werryc• / 'tts- aft y1ce_ o,VZ f -AFA+ At& lie -f' {•zj oT.o9 / ra✓ w63 ,ws c o— �,..e vgaViwt Applicant - Return all copie�to: San Joaquin Count P Sc Health Services e_ w47rG.r - L✓tl/'{v— qq qtr l Esvl ronmental Health Permit/Services �.,/Ye( a,,,e„ W'tzS !f0 �� 77P,6L( I =�'7 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 2� E AMOUNT DUE AMOUNT REMITTED CK / RECEIVED BY DATE PERMIT NO. . EM 13-24 MIN.v x el � (! EH 1628 b T