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AYYL1CATiOM FUti YUKKi'1' r n r amAQUIN COUNTY PUBLIC EEALTH ZVICES ENVIRONKENTAL HEALTH DIVISI e 1801 E. HAZELTON AVE. , PHONE (209)488-3420 P 0 BOX 2009, STOC&TON, CA 95201 (Complete in Triplicate Application is hereby mads,to Sas Joaquin County for a permit to construct Lad/or install the work herein described. Tn_a application is made in congliance with San Joaquin County Ordinance No. 549 and 1869 and the Rules and Regulations or gar: Joaquin County Public Health Services/. Y 3.55-5- wolf Lane 5?a tkrf Lot 81ae/Acreage /00 ' x/00 Job Address K1'MPr City /J i Owner's Name 6 u r �l' JAQ Ayi,.k Address Pa 8,, S 2 c/5- A.111+11tCd Pnone contracts �« ^4r� ,.Address q/694 ��irf ><r fit. FirMa'Ll�ense No. 5965`15 Pliant �IrS)6 Sy ovoY TYPE OF WELL/PUMP' NEW WELL C WELL REPLACEMENT r DESTRUCTION JK Out of Service vel. L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Vel. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP LINE i FOUNDATION daZ' AGRICULTURE WILL OTHER WELL..Sl-f_ PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Well Oef+r I ❑ Industrial O Open Bottom O Manteca Ma, of Wall EXOWstian De. of Well Casing .�_` C.1 Domestic/Private 31 Gravel Pack 0 Tracy Type of Casing f✓C Specifications fe A, r/0 —i I'I Public ::1 Other n Delta Depth of Grout Seat h S= S. T' Type of Grout, 'ej P. j i I Irrigation —.APpros. Depth I 1 Eastern Surface Seal Installed by Erc</J,, A /n e, F Repair Work Done U Type of Pump H.P. State Work Done i Well Destruction Jia Well Dunstan 9 .2 " Sealing Material i Depth Depth 19 r filler Material A Depth . 112 Y 1,e. se...f TYPE OF SEPTIC WOR NEW INSTALLATION I I REPAIRIADOITION I DESTRUCTION 11 (No tleplic system permitted if pubiic waver ie available winnir,200 feet.) i Installation will NY Reeltlence_ Commercial_ Other Number of O On, units: — Number of bedrooms CMrate f saes to a depth of 3 fate water table depth SEPTIC ANK ❑ Type/Mfg Capacity No. CorePenmants �y PKG REATMENT PLT. Cl Method of Disposal Distance to nearest: Wall foundation Props" Line s LEACHf INE 0 No. S Length of linea Total langtn/slie i FILTER BED M Distance to nearest: Wail Foundation Property Line i SEEPAGE,WS i I Death Size Number SUM,114 k.1 Distance to nearest: Well Foundation Property Line W6 0SAL PONDS ❑ nereby canify that 1 have prepared this application and that tris work will be done in accordance with San Joaquin county ordinances. state laws, an, wes and regulations of the San Joaquin County Home OwrAt or licensed agent's signature certifies the following; "I certify that in the penarmance of the work for Which this permit is issued. I shall no' employ any Person in such manner as l0 hisComa Subject to workmen's compensation laws of Califomia," Contractor's hiring at sub-contracting signature cenifiet the loaowing: "I certify that in the peAamenoe of the work for which this permit ie latued, I shall employ perwms subject to workman I Compensa, non laws of Calilanis." The apWkant r et can for 1 r irad Iaplctions. Complete drawing an revere aide. Signed X Title: P" 1�4 1I414o v✓ Dass: 5po _ FOR DEPARTMENT USE ONLY . APOIC&Nen Accepted by Data al Ar Pit or Grout Inspection by Data 0 Final Imapection by _ Data ' Additional Comments; Applicant - Return all copies to, Sea JeaquiR County Public Health Services, Ebvlroamatal Health Permit/Services t 1601 E. Reaeltod Ave., P 0 Boz 2009, Stockton, CA 94201 Aso AMOUNT DUE ) +AMOUNTrrRE11MITTED CAGH IVID ay DATECfeRMIT No. It�i iaa„e 1 1nst V.ir60,00 ."��V[1. ( /t7✓�l� t • d e0 : 22 06/10/01 3/D D .juC -