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Was �. --evil APPLICATION 30 �{'��, UII�,(,OUNTY PUELIC HEALTH SERVICES 'Is� 1` ,q't,Q Avrq!Wu-WENTAL HEALTH DIVISION L ZrJ1t 4>(1161 SAN JOAQUIN, PHONE (209)468-3420 S,n1�I�� P O BOX 2009, STOCKTON, CA 95201 ��v ly'jgA� PERS!I T�X,p I RES 1 YEAR -ROM DAj ISSUED �VNJ (Cc;mplete in Tripli(.atc) Application a hereby made to San Jc quln County ror a pe.-aft tc construct end/or install u• a work hereln descrlbed. This application is made In cocipliance vith 3an Joaquin County Ordinance No. 549 and 1862 and the Rules and Regu.ations of Ban Joaquln County Public Health Services. Lot! QF :i£CO/f if Job Address ?r 7 ,Si('!,/n 5r+I7 /t'rf Grv___%t7ilL_—_ L.ot Sise!Acrenge I 2.i c i�1'If!'2 e o n Address _S C/rt Phone Owner's Name ---- -----`--------'-- Contractor Cfazk Oe AP, In Address-'��-'_ _,_Cfbn^lr=----License Nu._;_560 Phone 46.'-7676 TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACIMFN�Fi'r DESTRUCTION L1 Out or Service Well Ll PUMP INSTALLATIONiLh SYSTEM REPAIR Cl OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK 5(b r SEWER LINES ,__—_ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS_ INTENDED USE TYPE Of WELL PROBLEM ARFA CONSTRUCTION SPECIFICATIONS (l industrial C70 n Bortom ❑Manteca Or, of Well E.uvatw Du.of Wait L tsfng 6 e Y Xbt'Oumestir./Private QCT Gravel Pack O Tract/ .l'pe of Casing /PvC--- 5poabc2 Tans cCN 2/1 I Il 0 h 1', Delta oepih of Gmw Seat 100 Type of Gtout CcmCn f C^) I�. PuhLK; Q ��-7�� I i I...I suon Z?3 ASIS.- Depth I 1 Eeslam Surlace SgdI Installed by f Ari rz4 _�_ 9p S!/Ck Renoir Work Done ❑ Typo of!•ump Sri C H P._—far State Work Don* Ga ?,;CrC4f Well Deatvction 0 Woll Dmmatar —__ eange -Ltiluii A /,,.n y r {•r f, f Depth` S6 t Fi 3er l4terial & Depth 0 ,r TYPE OF SLPTIC`NORK. NEW INSTALL.AIION I I REPAIR/Ar,,Dn ON I I DESTRUCTION' i (No septic system permmad d ptbftc aewsr Is available within 200 last.) t Installation will terve: ResidenCe_— Commercial_— Other Number of li,nng units:_ Number of bedrooms.�.� Charactar of SON to a depth of 3 lee(:— Water able depth SEPTIC TANK O Type/Mfg _-_ _. Ct,pac-Iv— Na. Comparimenti PKG. TREATMENT?LT ❑ Method of Disposal Diaence to nearest: W:'.l Foundeli•+n__ Property Line_ 4 LEACHING LINE ❑ No.6 Length of lines __ Total length/size FILTER BED Cl Distance to nt,arest: Wall Foundauun_ Property Line _ SEEPAGE PITS I I Depth _Size Number SUMPS LI Distance to nrsaresc Well_. Foundation___ Property Lira DISPOSAL POND'' ❑ 1 hereby csrt,fY that I hays prepared this applicatten and that the wort,will be dcne in accordance with San Joaquin county otdin.nces.state Laws, and rules and regulations o4 the San Joaquin Co my -_ Horne owner tv licensed agents signature ccalf ou the 1ol;owing:"I certify that in the performance of the work for v hick this parent is issued,I shall not employ any parson in such u:,rer as to become subtact to workman's compensation taws of Csllfornis."Contractor's hiring or sub-contracting signature n certilles the fcpowing:"I certify Inn?TTf1 Aormence of the work for which this;,smut+s issued,I shall employ persons su bjac11 to wL�fk n's eomp♦nu Base5 tan Laws of Cofifor is." I Li� 1 /Lr ��// f�/f r`! The apphcsnt to rI m. Complete Crewing on reverse side. q� �r1, (t+•5 �� •lnfnoY- C Signed — Title: 1t, Cfr/nk l:IePf, Inc Date:I /Uel 92 F DEPARTMENT USE ONLY App'+cation Accepted by - Z Date_ Area a ,'�.. Ph or Grwt Inspection by s Date Final Inspection by Date /a�J o AddhionM Ccmrnants: oK- _ _ ` Al cant -.Return g.l,l ry es to San Jeaquln County Publir. Ilnalth Sur,,ices )- x-40,11Eavlronawntal health Pormlt/3ervicee a 445 N San Joaquin, P 0 Dox 2009, Stkn, C1 95201 FEE AMOUNT DVE AMOUNT REMITTED K ,I RECEIVED By V-.T(H PEAM&NO. . Ln 13.24 IfIrv.Ira fr of - L✓DD•CID 91-�Yo