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APPLICATION LL�� µµ SAN .1 )AIQUIN COUNTY PUBLIC IIEALTII EB�OL _ ENVIRONMENTAL HEALTH DIVISI ��''��jj��nn uu �0 445 N SAN JOAQUIN, PHONE ('209)4 , 2V y370 .l� P O BOX 2009, STOCKTON, CA 9f2FAC ,l PERMIT EXPIRES 1 YEAR FROMT §N (Complete in Triplicate) i I IN V ftoar .QFVpr�7 Application is hereby msde to San Joaquin County fir a permit to construct and/or install the work herein described. This application to made in comeillance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joa,uin County Public Health Services. ` Job Address �� l ' M 4 1 4 go"� R pled _Crty -\I'lje 11 Lot size/Acreage tic Q rrC__ vl Owner's Nsms V 1�'"1 P Y "L 1 G�_ Address __��'1 Com— Phone I g-7--3 Conlracla r a rTn PLafnr' _ •darris- S ICP��_RQ�f(!_ _l�`1�5��License No.-3��Phone e `r) TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT I1 DESTRUCTION [.1 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR L! OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP LINE -LED FOUNDATION AGRICULTURE WEL. _— OTHER WELL PITS/SUMPS _ ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ! Li Industrial CJOpen Bottom 0 Manteca Du of Wan Excavation t O's. of we"Casing 7 G-,Dorrissuc/Private �Gtavel Pack Ll Tracy Type of Casing,._--.-__,]_ C Specifications Il Public I.1 Other I-1 Delta Depth of Grout Seat d0 Type of Grout h � I I Irr:pation _je_Approx. Depth I I Easternf Surface Seat Installed by Repair Work Dona U Type of Pump S,/�M H P. _.__ State Work Done._ Well Destruction O Well Diameter _ Sealing �tVAte ;lr{� Depth �- Depth ? )1Taa►�� a Depth ,Sl di TYPE OF SEPTIC WORK, NEW INSTALLATION I I RE PAIRM I STRUC i ION I I INo"Dirt system permitted d aublic sower is �\ j Y1 L 4Qc1t wadable within 200:Mt.I Installation wiil serve: Residence_ Commercial Q 3 .r,? ;} Number of kvrng units:_ Number of bedrooms_ i1QIJlN Character of soe to a depth of 7 fear. J ` Lj~ •11j1n zA WBPer table depth— SEPTIC aDth_SEPTIC TANK ❑ Type/Mfg __ *�tA`f aWcity— No. CanWrtmentit PKG.TREATMENT PLT.❑ E- Method of Disposal 7s Distance to nea.est Well Foundation PrFty�l•{rie~ "T +� LEACHING LINE Cl No.3 Length of lines Total lonith/li:e �[ I 1 / e FILTER BED ❑ Distance to nearest: Well Foundation Property lire SEEPAGE PITS 11 Depth Sve Ndmber qtj ot 4, s SUMPS LI Distance to nearest: Well _ Foundation EVnrUP16y Lilt t DISPOSAL.PONDS ❑ r 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 Sen Joaquin County y Hoowns.-or licensed agent's signature certifies the following: "I certify that in the performance of :is work for which this permit is issued,I shell not employ anyme person in such manner as to become sublet:to workman's compensation lawn of Celdornis."'Contractors hiring of sub-contrarting signature dyer urtdtes the logovr^g:"I certify d&1I in the performen.ce of the work for which this permit is issued.I shall employ parsons subject to workman"s companw- „"-{ tion Uwe of Calif r Tho spplican a all for ail r*quit inapt tam. Co�OR ng on rover"side. S;`� _ Tills. ;,�rgc��c c Drite: PARTMENT USE ONLY Applicltion Accepted by _ Date Ares Pitor Grout nepection by Oate 5 _ nil Inspection I Dole c — Addhkxul Comments: QQI{'3 bb— a7d -zNl�.�6 O Apel Scaa �Return all cople to: 39a.d��J oaqufn County Public health 9e rvicae SkW' X785-3.'AN• 15'11 Environmental Health Permit/Servlcee8111., 11380— ? 445 N San Joaquin. P O Box 2009, 3tn, CA 952e1 r� IFEE NFO AMOUNT DUE AMOUNT REMITTED K CEIVED BY ATE PERMIT NO. �. 14 13 74 IRIV a y�' EM uas 3 1 •`5 ��s�"_ ...,... ... .. .. .. "✓<ir.:e`aic''„ r"'.r.._..w.._,.._'us.'r+�kt4tiei