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} it APPLICATION FOR PERMIT '!' SAN AQUIN COUNTY PUBLIC IMILTH S VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (269)468-3420 " A Y!!q .,, P O BOX 2009, STOCKTON, ICA 95201 R C PERMIT EXPIRES 1 YEAR EROM DATE 5 OCT 2 (Complete in Triplicate) S.-:\J 10 I� P��L! Application is hereby made.to San J r r' j ,• Joaquin Couaty for a permit to construct and/or .'instal2=ft>4e�iroi]sj a n,described ,S This `�\1 application is made in cc�liance with San .T # oaquin County Ordinance No. 5L9rand 1862 and the Rules and AEA4t}atlonai.oS:'�9an Q Joaquin County Public Health Services. Job Addressi' 1�� 1, City kull�� Lot Size/Acreage Owner's Name � J Y OIL g . Address 1 OJ D� LA - u,1NAn1 ZA Phone ]] � . . _CanIracIOf` br-- I HA ��. r WIL ^� ° a Address911aC_.!-r.IZ�/Fe 9.�7��J License No.-54 ! Phone9fr ,!S'7 A TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n) J DESTRUCTION Out of Service well !` PUMP INSTALLATi1QN G SYSTEM REPAIR ❑ }{ERj Monitoring Veli ❑ DISTANCE TO NEAREST: SEPTIC TANK NIA SEWER LINES 17 DISPOSAL FLD. PROP. LINE FOUNDATION !-{� AGRICULTURE WELL i OTHER WELL ` PITS/SUMPS !L/—A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP6FICA710NS 17 Industrial C1 Open Bottom G !Manteca Dia. of Weil Excavation Dia. of Well Casing n Oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �� Specifications I'I Public fa Other n Delta Depth of Grout Seal �� Type of Grou I I Irrigation _ _Approx. Depth I i,Eastern Surface Seal Installed 6y Repair Work Done L1 Type of PumpH.P. 1rStatQ Work Done Well Destruction Well Diameter Sealing Material i Depth I 1? 7 f S eoJ f^ Depth sC Piller Material i Depth ij rvl TYPE OF SEPTIC WORK; NEW INSTALLATION I I RE PAIR IADDITION I I DESTRUCTION I I INo . se tic system permitted if public is 1 Installation will serve: Residence Commerdavailable within 200 lest.) at Other i9 Number of living units: Number of bedrooms 4 i Character of sal to a depth of 3 feet: h l Water!able depth SEPTIC TANK. ❑ Type/Mfg Capacity l No. Compartments ; PKG. TREATMENT PLT.❑ Method of Disposal U Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER HED ❑ Distance to nearest. Well Foundation Property Lina 3f SEEPAGE PITS 11 Depth Size Number e SUMPS LI Distance to nearest: Well Foundation II Property Line DISPOSAL PONDS ❑ I� I hereby certify that 1 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 performanc@ 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 6iifornia.'� 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'emptoy persons subject to workman's compensa- tion laws of California," The applicantIl for I r ired inspections. Complete drawing on reverse sid@. , Sig Title: is F-Akhr�" lmr-M -" r rr Signed i.. � � Data: R DEPARTMENT USE ONLY Application Accepted by Date Xeo Pit or Grout inspection by Date incl inspection by Data Additional Comments; I Applicant - Return all copies to: San Joaquin County Public Health Services'' Environmental Health Permit/Services 445 H San Joaquin, P 0 Boa 2009, SC'kn, GAII95201 h FEE AMOUNT DUE AMOUNT REMITTED GK !NFO CARECEIVED BY DATE PERMIT'NO. CASH .nom . EN" 3.241NEV.i KS) �� 7d 6323