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APPLICATION . :.r 'k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SR `VIRQ'TMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PRONE (209) ?68-3420 P 0 BOX 2009, STOCKTON, CA 95201 3 a PIT E%PIRP,S_T YEAR F1061 DAISIOSUED y + (Complete in Triplicate)` f „'r : , a w Application Is hereby made to San Joaquin county for a permit to construct end/or install the vork berein deweritxd )�YRfiax `afx arpltcatitm is ads in compliance vith Ban Joaquin County Ordinemce No. 544 and 18� a� she Ttulrs and NesuLtiona a! r 1j s Joaquin County Public Health Services.• { r f / Size/Acreage l i � H ry Vit., Job Address �r� e•; Y �t ” Phone Address — Owner's Nsme -"�►�L,��b;: _ v$ Address ense No. hore y C„ntractor WELL REPLACEMENT.CT DESTRUCT ION,C PE W W S,Out of,8grrice,Re11 ❑ ; r TYOF WELLIPUMP: NEELL ❑ Monitoring Nall tp PUMP INSTALLATION ❑ -SYSTEM REPA!R ❑ OTHER ❑ f A .tor DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP LINE` FOUNDATION AGRICULTURE V.ELL OTHER WELL INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 A_•„ ; ++ t qx r gid t t1 Industrial ❑Open Bottom ❑Manteca Dia.of Weil Eacavrton _�� DID.of Well Cattnq °y pomeuiclprvete CGravel Peck ❑Tracy Type at Casing Speci}icationa s - Tips of Grout is „ r ff fl Delta Depth al Grout Seal �- I'I Public I'1 Other talar'' '�; r i I I Irrigation _Apfxos.Depth 1 I Eastern Surface Seal Installed by - +HtY{7 ppeir Work Done U Type o1 Pump H.P. P. - Stals Work Dons-_:'"' `• Sealitl6 Material a Depth Well Destn.•cflon ❑ Well Diameter 2 ` Fr t °xf Depth v Filler flaaerial i Depth N 'r ri x r he system rmiHed II public sewer Is v TYPE OF SEPTIC WORK, NEW INSTAt,1 ATION PAIR7ADDITIDN! I DES7RUCTtON I p W p svalNtble within 100 feet Insiallltion will serve: Pasydance� mr-Imiet_rOther r .. Number of Ilvinq units:_r Number of r m �.•? < M, Water tab4 depth �hsrecltr of soil to a depth of 3 feet: v ' �ypalMt ' /tr,d� N6,compartrnrma 1� � SEPTIC TANK" g CaPaeitY-/ V� +. PKG.TREATMENT PLT.Cl �� rNrn� Method of G�pos+l � Distance to nearest 4. Well Foundation Property LirN Y31Y it .i - i3. tar Gr _ LEACHING LINE 6 Length of f'nes Total bngth/alae rya t`l_$ ) '• ,. .`?. PtLTER BED n Distance to nearest: Wea QQ Foundation ' Property lino^2 u aP k i SEEPAGE PITS Ipth �a-� _Si:a Number r x f� * La •i SUMPS LI Distance to nearest: Wall Foundation 10 - Pips".'Line knnyjx f DISPOSAL PONDS ❑ I hereby crrtify that I.have prepared this application and that the work will be dons in accordance with San Joaquin county ordinances,sillo taws and ruiea and regulations of the San Joaquin County { "` Horror owner o'licensed agent's oigneture cerlihas the following:"I certify that In the performance of the work for which iiia permit to Issued,1111111411 not tr employ any person in such manner as to became subject to workmen's compensation laws of California."Contractor's hiring or sob eontrletlrtQ wy..wre certllias the following' I is Issued,I shell ampiby parsons subject to workman s camgnas "I certify that„t The performance of the work Icr which this parc f California." i �.'�i... `• Th -applicen t e fatal mci ins 'ons-C e rawing t Date: Titw -- t Spr�la� { FO EPAR NT USE ONLY `• moi; 4 Application Accepted by 7 s � a t t Date Find I apection by r's,•f Pit or Grout InopoKtion by nal Cornments: Addi[la co e Applicant - Return all copies t0:~ San Joaquin Coucr.y Pubite Health Services r .Envtronmentel Health Permit/9er�lcee l 449 Y San ,.'oaquln, p 0 B6x 200C, Stkn, CA95201 , FEE AMOU�011 AMO�MIEMIrT�ED LKICASH nECf1VEG flu OATf ►El1MtT'NO 1NF0 �}I• FM t17i IREV,srnniV'tF F•r , ',�:r ;�' Flt f1.7a .ar C