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J APPLICATION Ar SAN JOAQUIN COUNTY PUBLIC HEALTH sw)r-E-1 � ENVI.RONVENTAL HEALTH DIVISION a " firk in 44SPN SAN JOAAUIN, PHONE (209)468-3420 4 "° •�, t . I _ O BOX 2009, sTOC$TOx, cA;95201 t .. t—� E%pIRBS I YEAR ,EtQ�ATF. T�SNy�Tlt'f] r (Co[riplete in Triplicate) 1pplloatiaa is hereby made to fun Joaquin County far a permit to construct and/or install the trork herein descrlbrd.- l.lt' ' aDDllcatlab is suds is OW11ance with Bari Joaquin County Ordinance No. 5lrg and 1 2 end the Rules'and Relptlatleee of San Joaquin County Public health serv1ces. '^.. Job Address + City Loi Size/Acreage' %. . OwMr'a Name Addfess .!L_ 2 4, '1 -one Canbaclor,�S Address`7V J ((.Ir.�Ji•i L•cerise No fl3 p: Phone TYPE OF WELL tPVMP: ^NEEW WELL ❑ WELL REP CEMENT C1 DESTRUCT!oN 17 Out,of$errin.,Ve PUMP!7r_TALL47ltlN C] 5Y fM REPAIR ❑ OTHER ❑ MOnitor'nft Vel] DISTANCE To NSAIIEST: SEPTI:TANY 5EWE LINE DISPOSAL FLO. PROP LINE u i FOUNOAVON AGRIC L7 RE WELL OTHEA WELL PITS/SUMPS INTENDED USE TYPE OF Y+ELL PROBLEM ARE CONSTRUCTION 5F:CIFiCATIONS ❑tndusrrial ❑Open Bottom ❑Manteca Ola. of Wen Excavation Ula of.wan Casing �. CI Domestic/Private Cl Graves Pack ❑ Tracy/� Type of Casing-- SpeerficatgnsA—'" r i'1 Public fa Other n Dei± Dept,of Grout Seat Type of Grout ;' I I trrlgatWn ,,.,�Approx.Cepth I i E tern Surfacu Seal installed by � f «Ira t Repair Work Done G Type of Pump H.P. Staff work Dona ' weli Destruction ❑ Well Diameter sealing Material a Depth ' , • �< Depth Y11ler Material A Depth - TYPE O>=SEPTIC Wt7RK: NEW INSTALLATION i REPAIRlADDI! j i 1 DESTRUCTION! I No seolic system F f gys �•' -t Ya permitted+1 public sewer is„ .. ava'lablt within 20Q feet.l �..-.; , _ a Installation-Adil serve: Residence�Commertia± Number of living units:__ Number of bedrooms : Character of Boll to a depth of 9 feet: SEPTIC TANK O Type/Mf ui water table depth. Qpacity C. No.Cpmparrr+nti PKG.TREATMENT PLT.r3 y r �/' me thod of Dry + Distance to nearest: Well _ foundation Property Lina jt LEACHING LINE _ C�. No.8 Length of nnet To I length/size r FILTER BED n Distance to nearesu WeR d x a _ - Foundation Property Line arc " 4r s a aS SEEPAGE PITS' 11 Doose Sire Number SUMPS L i Distance to nearest: Well k 'r a Si Fountlsrion'_ 1 Pr F' a > Dt51'Vr.AL PONDS r] - Property Line� .�, 1 r»reby versify that 1 have prepared th+e application and that the work will be done in accordance wr.h San Joaquin county prtlmancea'staff lewe''tnd , -rules and rtgulalions of the San Joaquin County - - Home owner Of licensed ag�ant's signature certifies the foflowinQ:"I cattily than in the Performance of the work for which thy” ampfOy any person in such manner as to bocc;vw subject to w.�rkman's compensation laws of California."Consraetols hiring Or lrracentr I sw not t certifies the following:"I certify t.nat in the f.erformance of the work for which this +n0 arpnetutt r tion taws of Cfiifornia." permit is iasueff I"ll employ parsORs sub*-t to workman,g comprtrtaa 1, The applicant - call for Mt r incpecti s.Camp!gle drawing on reverse aide. Signed ' 3'f'f iF± q, •^tr ., g Tine: _< [/ R D RTAIENT USE ',NLY Application Acc*prod by C)— f ' Date_. Y Area • it Grout Ir,apection t'y� to Final Inspection by Dfn S Addhional Comments: Applicant •• Return all copies to: San Jo¢quia County Public Health Services Environmental Health Per,rslt/Services 445 0 Stn Joaquin. P n pox 2009, Stkn, CA 95201 FEE INFO AMOUNT OUE AMOVkT IIEM17TEp i RECEIVED 6Y �• CASIt DATE PfgMl7 NO "', �F. ! FK 19"7l lRty.1��615� 1 OQ Y { °; .,yam 'J :} r } - - A Y 1 �7e �j Y