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b APPi.ICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC, IMA.LZIN ENV I RON1[ENTAL IIIsALTII D I V445 N SAN JOAQUIN, PHONE (20qqf,5- P O BOX 2009, STOCKTON, CI1 PERMIT-F.RPIRES- L YEAR FROM D f (Complete in Triplicate) IV Application is hereby rsade to an bJoaquin County for a pertilt to construet end/or 1 ■txily�•tH! Y, ' application is made in eoglllaece vlth Sar, Joaquin County Ordinance No. 549 and 18 0 ^ 1Fe Joaquin County Public Health Bervic4e. lg3�rsN, fly, _S Job-Add1t C,lv 4ot 3e/Acreage � reu O / ; Owner•a Na,rw A ddress Phoma Con[ract�lt1A't cys Address r � r`^rLtccnse No. 2133� Phone TYPE Of WELL,PUMP: NEW WELL Q WELL REPLACEMENT Cl DESTRUCTION ❑ out of Servlce Well LI ?loaitoring well PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ R DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOU NOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ~ t ,rxcr ,. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' C7 Industrial. C7 Open Bottom ❑Manteca Ois. of Well Excavation D4.of Well Calling.. 's l fl Dorryaic/Private' 0 Gravel Pack C] Tracy Type of Casing..- Soecificalions �' 1 sd" _•;l =,L y L'1 Public fl Otter [•1 Delta Depth a1 Graur Ssal Type or Grout 4- 1 t 1 Irrigation - .._Approx. Depth I r Eastern Surfed Seal Installed by \ _• ' s� i41 Repair Wort,Done U Type of Pump H.P. Sate Work Done Sealing Materiall Depth :." Well Dnttuction 0 Wail Diameter t Depth Tiller Material A Depth 1 I TYPE OF SEPTIC WORK: NEW INSTAL TION a REPAIRIADDITION 1 I DESTRUCTION I l INo septic system pm+uubh ed it pe sever is ,1// .. 4 available Within 2W 11"I.1St M _. Ci �r.._rt Innadation will serve:"Residence ommercial�• Other *F / } '� i� •^ilr-„k Number of living units: Number of bqro ■ - r} ' Clwaeta of soil to a dep of last: Water tabM,depth OCG T E. ;rt"'�t�ri '�4} •, SEPTIC' 9,Typ"fp CsPacitY p' No.Compartments. r PKO:TREATMENT PLT.❑ / / Method of 049og1 ' Distance to nearov: Well Foundation/Q� �ropertY Lino LEACHING LINE Yo.8 Length of lines — Total tsngthlsia - 4 FILTER HED +a Distance to nearest; Wed-.5A '70' Foundation ZQ 11" Property Line lit SEEPAGE PITS Depth - Sits lumber � !i tt, r rit5 r SUMPS LI Distance to neermt: Wellfad, Foundation_.,�Jc—�. Property line x DISPOSAL PONDS` C7 I hereby comity that I haw prepared this applicatton end that the work will be done in accordance with San Joaquin county ord^unces,stele Laws,and f."AM x rule end regulations of the San Joaquin County k Home owner or licensed epent'e signature conilin the following:"I ramify that in the performance of the work lot which this permit Is issued,I shell not y r employ any.pereon In Such manner as to became subject to wotlinisn's compensation Laws of Cllilornia."Contractor's hMing at sob contreeting signature 2 y•-_ .'e-•};�. :`' cerlHiea the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's entrtpenaa• ° .' •ivy ire floe lawn ofComornw... The epplkeru s call Iso a0 inspections. Complete drawing on rwerse■id ' at i+ y Signed Title: Oats: FOR 02PA,RT7MENT USE ONLY Application Accepted by Date�, Area, ? „e�"L+r��Finaline y C��°f Grout Inapettlon by Aau _ inspection b Additlonal Corrtrrwnts: ' Sea Joaquin County Public Health Services 2APP1lcant Return ell Coptea to; ' - Evviroataentel 1[eelth Pnrml t/Servlcea ' a teat rk 8° - - 445 N San Jaequin, P O Box 9009, 9tltn, CA 95201 AktWNT out AMOUNT REMfTTfp CASH RECEIVED eY PATE PLRMIT"NO. I.2 b i l'S�� 1.�t i a .[h 11•Ia IR[V,7r•at V� -i 'FH t4Y }" ..4 41r 1 f11 r