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Ik iAT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES "` ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE OTON(2CA)9b201420 P O BOX 2009, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (Complete in Triplicate) Application is hereby Leede.to li San WithuSanCJooaaquin County Ordir a permit tnanceconstruct No. 549and/or 1662Install and thethe Rules andherein Regulationsdescribed. of Sans application is road" in camuplianee Joaquin County Public Health services. 1 City liot Size/Acreage Job Address Phone W r L Address Owner's Name _ Phone Contractor ��tiff S � Address License Nv. Contractor ��" DESTRUCTION 01 Out of Service Well ❑ TYPE OF WELL/PUMP:j NEW WELL d WELL REPLACEMENT n Monitoring Well C7 S_Y-STEM_fiEPAIR- ,.-_ .: OTHER PUMP INSTALLATION_: ,.T .•=�,max '". __Y 1 ... + DISPOSAL FLD. r PROP LINE SEWER,LINES_ _ �- DISTANCE.TO.NEARESY:_SEPTIC TAN> _'. T,,__,�_ - "-'" PITS SUMPS %1 'AGRIGIJLTIJRE WELL OTHER WELL— FOUNDATION �-- INTENDED USE ` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing Dia. of Well Excavation C7 Industrial ❑ Open Bottom ❑ Manteca Type of Casing_ Specilications EI Domestic/Private r ❑ Gravel Pack n Tracy Depth of Grout Seal Type of Grout I'I Public f:7 Other y.�. ,..__:.-n_Delta__ (� a. � rox TDepth I i Eastern �S ace Seal Installed by ifi Irrigation i ppp �'r - State Work Done ` bl Pum H.P. Repair Work Done LJ Type p i f Sealing blateri'al & Depth k t Well Destruction ❑ , Well of Filler Material &.Depth Depth TYPE OF SEPTIC WORK; NEW 1NSTALLATION 14^^HEP�ERlADOITION I stem i DEST CTION I l aNaila le�within 200 lae_t111��+�P`rblic sewer is i Installation will serve: Residence— Co' marc1 Other a Number o1 living units: Number of beRr0-0- i s t Water table depth Character of soil to a depth of,3 feet: *"• � T t. i No. Com SEPTIC TANK ❑ Type/Mfg - �- Capacity_ Meth-RINEW PKG. TREATMENT PLT. ❑, 1� 10 f t f 2 s Foundation --- Property Li — Distsnce`o nearest: Well ! I Total length/sizwfq JO's LANI v, LJNT' j LEACHING LINE C1 No. 8 Length of lines .. P P . ' HEAL FILTER BED Ci Distance to nearest: Well Foundation ? l iE V t tL r li 1.)iV, ;o u Size Number SEEPAGE PITS I I- Depth ` + SUMPS ,.-..�- :L1 .Distancerto pearest: ell_ ton -P_rope Line t DISPOSAL PONDS ❑ I I hereby certify that I have.prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawand s, rules and regulations of the San Joaquin County work for this permit is issu Home owner or licensed agent's signature certifies the following: "I certify compensation ln the awsofperformance of Contractor's hiring or sub-contracting signature employ employ any person in such manner as to become subject to workman's comp the to owing: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- certifies tion Iaws o� iifor r The appl nt t calf ftir all req i ed inspqctifn5. Complete drawing on raver side. j Date: Title: Signed 1. FOR DEPARTME USE ONLY i Date 27 Area �� 4 Application Accepted by7i$ �rL l hit or Grout Inspection b I Date - Final Inspection by Date i i " Additional Comments: Applicant --Return all copies to: Environmental oHealth unty uPermit/Services blic Health vices 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ` CK RECEIVED BY DATE PERMIT N0. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO " i EH 13•21 lR1Y.f/x Sl -R ' l EH l4-1b f