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�. APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 1Services. JobAddress �`�� City rCA e_4 Lot size/Acreage he_ Coni a Cv� Owner's Name TCusArnev I�jvh�_ Address P,0, QOb��b J3eh2C° lLL(/t' Phone 707-6 Ar f-r F '(7S)keyhw- Mild, �Y��l 1 6 Phone �80 Contractor Sl,Clh�-NV-�� Address_ Icense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Weil ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ l3op-INSS t�T�;: Monitoring Well -- DfSTANCE.T-0NEAREST: SEPTIC TANK 7 fa° t SEWER LINES f<15-0 1 DISPOSAL FLD.>/00r PROP. LINE FOUNDATION6 ASO r AGRICULTURE WELL 104' OTHER WELL SO r PITS/SUMPS moo INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 14 Dia. of Well Casing NC t l EI Domestic/Private ❑ Gravel Pack ,t Tracy Type of Casing_ ALONE Specifications WA ) 1"I Public El Other n Delta Depth of Grout Seal Ary e- Type of Grout Alt-WE I I Irrigation -2 Approx. Depth I I Eastern Surface Seal Installed by C-M a AJ?- Repair Work Done L7 Type of Pump N/A H.P. State Work Done _ (� Well Destruction ❑ Well Diameter // Sealing Material & Depth Al f r Az r-6F^)r V� `3o2AW,s 2 Depth -71 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms P ,Y Character of soil to a depth of 3 feet: Water table de t ' MENT r{, SEPTIC TANK ❑ Type/Mfg Capacity No. CompaAWKWEIVEn \_ PKG. TREATMENT PLT. ❑ Method of T'E9a2, 4 1993 Distance to nearest: Well Foundation Property Line SAN QY7IN COUNTY LEACHING LINE ❑ No. & Length of lines Total length/sizg FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 'SUMPS` `- —tl---Distance to nearest: Mtell- Founbwtidn "Property Line---- DISPOSAL ine-' —DISPOSAL PONDS ❑ 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X /?�t--- Title: 01-0 U �10G7L E/UV13 VCS• Date: ;2 �2 3 =IP9/Q_r-CJ,AV >51V V n /1101VA ✓i �— CANS•-� FOR DEP RTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date 3Final Inspection b r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/ServicesG}/y� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO /� J� CASH y/ /^S// h/ C 2 . EH t3-24IREV.riHsi ��V / �� ( / VI ^ �J / EH 14.26