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• � APPL tCA Il ON n-. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' I 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009 , STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM JLAULLUMM l` (Complete in Triplicate) A,plleetiao lS hereby raj; to Sas JoatuSo County ! r a per:!% to construe: and/or install the work he-.e!1 deserted App!!eatloe is M44 In cc..F'..1!anee 'with San :eaqulnDCoua!y Ordinanea Ne, ;bo end 1?c? and the Rulea sad P.egslat!ens Jeu1u!n county Publle Nsal•Lti Se"icee. Jc; Address 5400 Paclic Avenue ti,Y Stockton Lot Slte/Aeresge _ MontgolnerI Ward 5400 Pacific Avenue (415)1919 2277 Owner's Name Address Phone Auto Service Center 3233 Fitzgerald Rd. Contractor W a4m6D i 1 )Aeolus Rancho rnrr3nir=. QA L-ctnst No. X4979 2(916) 632-727d TYPE OF WELLiPULIP; NEW WELL G WELL REPLAMMENT E7 ' CI Pn0. of Se.•r!r. ee 1 PUMPINSTALLSTICN Q S`iSTEMREPAIR C. OTHER _rr Flon!tcrinE mel: Li DISTANCE TO NEAREST: SEPTIC TANX 5EWER LINES 0__150 ft. DISPOSAL FLO. PROP. LIKE FOIJNOATiON AGRICULTURE WELL OT4ER YELL PITS/SUMPS INTENDED USE TYPE OF WELL PROSLSM AREA CONSTRUCTION SPECIFICATIONS !, Indusuisl L7r n Boncm Jr man;eca Oie. of WellEscava tion Dia, of Well Casing N Oomssticlpoeate !? Grsvel Falk Li Tracy Type or Casing, Spsdlicaticm .• 11 Public 1 other E 91 De th of Gout Seel X Soil Borf'il g p Type of Grout__._. 111,60stion 30 —tupnrot. Depth I I astern Surface Seal Installed by t Remair Work Done U Type or Pump H.P. $tats Work Done — .• J' YJalf Oesmiclicn 0 Well Dteneter $ea11;,g )tater!a15 Pept1: Neat cement C)„u,x-ru_ (0 ft—bottdm Depih Filler Material L Depth I I —� 1 TYPE OF SEPTIC WORK: NSA/ INSTALLATIOs) I I REPAIR:ADDITION 1 1 DESTRUCTION I I [NO septic system pe:miued it ;wt is ie.ver is I ( unstableI w�i�y�/T I tnstaeal7n vv46 ser-a: Reafc mee _ Cemmere!al _ Other R�i mC1Y i llumber of IFang ,rt+e: Number of badreoms RECEIVED i Chtraeter Of e0i! 10 a depth Pf 3 teal: KrJ#Nabla 2p1892 U SEPTIC TANK O Type/6112 Capacity '9I1° F tF 1 ' S A 4fAAM TNNTY ; PXG. '":i:.-iin " PLT. Ll 8L _ I PU 9 9A PWc39RVX1S, I Distance to nearest: Well Foundation —__ffff"NMEiNTA1 HFAI TH DIVISION LL St,r:;iG LINE G lo. b Length of tinea Total len2lhhiie_ FiL7E? SED 0 pistance to nearest: Well Foundation Property ane i SEEPAGE PITS I I psplit Sirs Number SUMPS LI Divanee to nearest: 146:1 Foundation Property Line DISPOSAL PONDS 0 f `sraby artily that I hevo prepared [his application and that the work will br Oora in accordance with San Jesauin cevnty crdinanas, seta losv:. Ir' •.'rs and taoutalions of the Sin Joa:i'ain County Nome owner or licensed agsnt;s iipvture tertifeS the following: -I certify that in the performance of the work lot which:his per.•tlit s issued. I shoo re employ any person in such manner as Io became subject 10 workmen's comperselten laws of California." Comrecter's hiring or mo•e Carl onvaetfr•g si2r rtifies the IC0win2;"I certify Thal in the perlormanca of the work for which this parrl'tll is issued, I shall employ psraor.s Subject to contract- co nae tion laws of Calilornia:' The applicant initist trill lot all I ed iaapeetionS. Complete drawing an reverse &ids. See Attached Figure signed y/�� >rGf/ ( Title, Geologist Date: 6 .16 92 J M KY ,4✓4NGW4 FOR DEPA7TMENT USE ONLY Application AOclplod by I Date J q � Area Pit or Grove Impec!fOn by Data / ! Z{:nal Inspection by_ Oeta Addidonel Comments: 7 3 Applicant - Return It copies to: Eon JonOvin County Public Naalth Services nLt v _Tow^.omental Health ForFezml c/ServSces --•---��--- 4.15 N San JOAfluln, F 0 Box 2002, Stkn, GA 96201 FEE AS•d Fn7-DUE AMOUNT RIMMED RECEIVED EY INFO CASH��jj�� '].DATE PERMflNO. ty11 iREy.rtaalr I 74I O ( p� Ib:t L/ 9z-