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V3 APPLICATION FOR PERNI"r SAN JOAQUIN COUNTY PUBLIC HEALTH SEIi I c/ ENVIRONMENTAL HEALTH DIVISlom �t 445 N SAN JOAQUIN, PHONE (209)468-31126 P O BOX 2009, STOC%TON, CA 8:M* PERMIT EXPIRES Y R D t��n1v� fTr1 (Complete in Triplica e Applicatlon is hereby made to San Joaquin County ror a permit to construct and/or install the work herein described. TnIs application in &%de in CoWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Refulations of San Joaquln County Public Health Services. atsSh, Lot Size/Acrea,e A G Job Atldre ty (� L �] Owner's Name !, S,LS N G�a R�h N • Address p • f Ls-'..1��. lsys s Phone _-_e, f Contractor ��2�__ +w..��!ifti�G Address ��7 ' E�CJ'�- 7� �Llcense ho.eaal13 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT t-1 DESTRUCTION> Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK y'�,(2.� SEWER LINES DISPOSAL FLO. PROP. LINE I-W FOUNDATION __ AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Ore. of Well Excavation_ Dia. of Well Casing f.i Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_-- SPacihca0crns ('I Pudic ❑ Other fl Delta Depth of Grout Seal Type of Grout I I Inrpalw __Appiox. Depth I I Eastern Surface Sorel Incralled by Repair Work Oona U Type of Purnp _�__ H.?. tate Work ora _ Well O"tructlon '§� Wall Diameter 1,q, Seating Material A Tiepth rw �,�{ X n (C[J7✓� Depth 4 n Filler Material A Depth �_QI DM LJ . TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOIP,ON ( I DESTRUCTION I I Mc septic system permitted it public rower is available within 200 feell ` n Inswltstgn will serve: RMidenu Commercial_. Other Number of living units, _ Number of bedrooms Character of soli to a depth of 3 tact: Water lana depth SEPTIC TANK ❑ T \ ypaJMlg CaPacitY No. CompartrtVnu � PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest Well _ Foundation _ Property Lin LEACHING LINE C1 No. 6 Length of linea _ Total length/size FILTER BEO ❑ Distance to rseanst: Well Foundation — Property Lina SEEPAGE PITS 11 Depth _Saco Number SUMPS LI Distance to rtMrnt: Well Foundation Property lin DISPOSAL PONDS ❑ I hereby certity that I have prepared this spphcafion and that the work will be done in accordance with San Joaquin county ordinances, slow awn, and rules and regulations of the San Joaquin County Home owns,or IicUaed agar's signCurs Oarl-l"the touovvnfi. "I comity that to the performance of the work for which this permit is issued, I "if not employ any person in much manner as to become Subject to workman's compensation tows of California" Conlfectoi s hiring or wb-contracting signature com ilip the following: "I comity that in to performance of the work for which this permit is Issued, I shall employ parsons subject 10 worknun'm comtpanu- tion awe of California." The applicant must call for aF required no apeeno a. Gomplate drawing on reverse $� Signed sKl�_L,i v / z/3( / \ A AA6 LI p3-` Title: '� L`L 2"r � Dow: _ FOR DEPARTMENT USE ONLY Application Aeeapiod by Data Area Ph o/Grout Impaction by Date Final Inspection by Datal Adahbnal Comments: Applicant - Return all copies to; Ban Joaquin County public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2000, Stkn, CA 95201 _ INFO FEEAMO%U�NT/D'UE AMOUNNT REMITTED CABN RECEIVED BY DATE PERrM`I"T'T"N—TO'.','/ EFA H 141111 . 11-61 W� ,Q.6L� C> D D >Y / �)/� --,2NdI