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111SSS � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is 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. Job Address 25600 CLEISM RCD - City Tp0cy Lot Size/Acreage 445 AS Owner's Name M= DTS=ITTCN.LdFSI Address 296M DAITSYAN RM Phone { ) — yy 602 381- Ei77 PF F99r1;FFRJTA-4W- DRI � �'ASCAN 'Address License No. 60 Phone l:t1n[tdCto( TYPE OF WELL/PUMP: 1 r NEW WELL ❑ j ! WELL REPLACEMENT X DESTRUCTION C) Out of Service Well ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 r DISTANCE TO NEAREST; SEPTIC TANK -WA SEWER LINES 400 DISPOSAL FLO..W_A PROP. LINE 2SOr FOUNDATION L 60' -:AGRICULTURE WELLINTPE OTHER WELL- � PITS/SUMPS" ..NLA INTENDED USE TYPE OF•WELL,' PEOWLEM AREA CONSTRUCTION SPECIFICATIONS it _ } fnd`ustrial 'f Open Bottom s- V❑ Mani teca.\`.'�� Dia. of Well Excavatior0 tF i Wel ( of l i -1L 16r, C I Domestic/Private CSI Gravel Pack ' X Tracy n Type of Casing__ rSpecifications ' 1'i Public l-i Other n Delta Depth of Grout Seal _" 0"4� S.iQ,;lt (Type of Grout 9_ Cdm I i 4rigation _..Approx;Depth f I I Eastern Surface Seal Installed by ATr,=AA1F&=WkZRR aMY CF _ Repair Work Done U- Type of Pump a k H.P. State Work Done Well Destruction. CD Well Diameter rr' Sealing Material & Depth 0-400 9-SAX CR� f Depth " t 950' Filler Material & Depth SILICA ZqNID j TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I-I, DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feat.1 Installation will serve: Residence Commercial Othtr" Number of living units: . . 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. ❑ f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & L6ngth of lines, 1 Tdfil length' size FILTER BED ❑ Distance to nearest: Well- Foundation;-! Property Line SEEPAGE PITS 11 Depth , 3- -Size �,f` Number SUMPS ` LI Distance to nearest: Well f=oundation Property Line DISPOSAUPONDS Ci I 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 California.—_'. The applicanVTusi call for all required inspections. CmpI to.,drawing on reverse side. Signed X L Title: 15eJ 1 C0L7eN7 Data: OR EPARTMENT USE ONLY r'J� L: _ O_ J Application Accepted by Date Area F - f,.�` Pit or Grout Inspection by f Date_ Fi ai_Inapection by2L.0—6di Date r Additional Comments ./ Applicant - Return all copies:to: San Joaquin County Publ a Health Services Lt.ICf(�' '! �� "X., Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 uT 37 oxcGr` a..�s . FEE AMOVNT DUE AMOUNT REMITTED CK H RECEIVED 9Y DATE PERMIT-NO. INFO 1 00. EH 13-241REV.hits) �! EH t4--Te «r11V!! _ i