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I' APPLICATION Y�J SAN JUA141.11N COUNTY PUBLIC HEALTH )EM UL _ ENVIRONMENTAL HEALTH DIVISI 445NSAN JO009IN, PHONE 9(209)4 eNa# y �D rHC# hti L RLMIT FZPI ROM DATE -1 PO (Complete in Triplicate) � Application Is hereby stale to Baa Joaquin County for a permit to construct and/or install the work herein described. This appllcatleo is Ilta4e In Compliance with Ban Joaquin County Ordinance No. 549 and 1862 and tha Rules and RegulAtions of San (� Joaquin County Public Health Services. ,f/I ^7 Job Address ZZ Y►'1i Iia Raai __ C.Iy L�1'lae� Lot Site/Acreage [,0 alre/ �C V I C k; Kcyt r�ck Address �S�L _ 1`-3 m f Pisan. Owner's Name J�,�h Anu�� D _+�{�-�`�-I_-_ �W L Phone 7 030 I Conlr1c10r �d�n irU � Address S /CP9_ t✓ License No.}lv TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT 171 DESTRUCTION 0 Out of Service Well PUMP INSTALLATION 4— SYSTEM REPAIR Ll OTHER O Monitoring 4ell n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WE,,L __ OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S C'rdvatnal O Open Bottom ❑ Manteca Drs of Well Excavation Dia.of Wall casing EUorrrstic/Private CjAGravel Peck ❑ Tracy Type of CasSpecdcations— r 1'1 Publk ('1 Other (I Delta Depth of Grout Sail 100 r Type of Grout <LJf'/7�' I I Initiation )JOL Approx. Depth I I Eastern f Surface Soul Installed by__ a Repave Work Done U Type of Pump 1,of�jd H.P. I IY ,__ State Work Done_ k8ealing Its .Y L Digiti Watl 0e"truction D WellDiarrsster Ar�I 1 Depth 1 Depth -� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRM SFRUCT10N I I INo septic system permitted d puWrc maws,is s 1q1141 available within 200 Net.) Installation will asrve: RgidtNtce_ Commercial_ 0�`�—V7:1 Number of units:_ Number of bedrooms_ 1JIN G , Character ofsok to a depth of 3 fest: AQ LTr �+ ._Water lsbla depth SEPTIC TANK O Type/Mfg 'x,15 A�- specity No. Compartments PKG,TREATMENT PLT.D '-"' Method of Disposal Oietan"to nearest. Weft Foundation Po(Ity Lin@~•'T LEACHING LINE CI No.i Length of lines Total knith,/kis FILTER SED ❑ Distance to nearest: Wall Foundation Piopeny line SEEPAGE PITS I I Depth —Si" Number SUMPS LI Distance to nearest: Well �. Foundation EfvnNUPlQlpariy tVl@ _ DISPOSAL PONDS ❑ iiRJRJ I hereby conity that I Neve prepared this application and that the work will be done in accordance will San Joaquin county ordinances,state laws, and ruk"end ratputatwis of the San Joaquin County Home owner or licertaad agent's signature certifies the following:"I certify that in the performance of the work for which this pernvt is issued.I shah not ` eo ploy any parwn in ouch ntunM ss to becort»subject to workman's compensation laws of Cablotnis."Contractols hiring or wPcontrectong signature eMlfiN tft"following:'1 c"fy that in the pertormancs o1 the wwk for which this permit is issues,I shall employ persons subject to wwkman's compensa- tion law"of Caw T"applican ca/Ire su n tions. Compete dr g on reverse cede. Signed Titla: Date: s OR DEPARTMENT USE ONLY r AppYcatlon Accepted by Oate Area Pit rout rMpection by Dat@ Final Inspection by Date AddltbnN Cogr~t@: VZOU Q�� Appllcant - Return all coDle to: 3Sapioaquin county Public Health Service's bbr rA7�y-2N U.11 - 4 ��{/ Snvlroomental Health Permit/Services �3so^sf�t>�.2785-=A+i/• 15''�� /O / 445 N Bas Joaquin, P O Box 2009, Stkn, CA 932x1 j �� 1Nf0 AMOUNT DUE AMOUNT 11EmirTED K CEIVED 9>,-) ATE f EEAM17 NO. .au 1344 tally.rtes, ,� / 15 �/ / -,7_ all � �mer�� •^'^-' ._�_ __._-.<...o...�uu....� .�.._ .:.ar�,:Y:.ic:r+.era;`•"S�;lc^si4��1iH'�"�'�ir,ttm.a.u�e5+..�w+,_.. .�».._.<,s,...Y�.;4ytk►.