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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVI ppb 7a3 <br /> • 445 N SAN JOAQUIN, PHONE (209) 6 <br /> P O BOX 2009, STOC%TON, CA 541b # 610 <br /> PERMIT EXPIRES 1 YEAR FROM D T <br /> (Complete in Triplicate ��/��^ <br /> Application in hereby made to San Joaquin County for a permit to construct and/o i t vork b ere iWvAmbed. This <br /> spplicatloo is made in coMPllance With San Joaquin County Ordinance Ho. 5L9 and Q� B OF of 601 <br /> Jeaquia County Patlie Health Services. �'(�(J�j y! ��y///�, ,,) <br /> Job Address 2 9�^y+ TJ� T "A,t7a) l/�s`9 � P /v'�iCC1Iy Vf ^� Lot Btze/Acreage <br /> Owner's Name ff Lok"f�/ l fk epi kddress l a /� _ Phor>K" �e `• <br /> Contractor Sz'-z d'll 0�_ AddressLicense No> 7 f� Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Vail ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C Industrial O Open Bottom C: Manteca Dia, of Well Excavation_ Da. of Well Casey <br /> LI Domestic/Private ❑ Gravel Pack 17 Tracy Type of Casing_ Specifications <br /> I'I Public Ll Other it Delta Depth of Grout Saa! Type at Grout <br /> I I Irngauon _Approx. Depth 1 1 Easlern Surface Seal Intolled by <br /> Repar Work Done ❑ Type of Pump H P. State Work Done_ <br /> Well Destruction ❑ Well Diamater Sesling Material a Depth <br /> Depth Filler Materiel : Depth \5 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAMJACDI TION i 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 1002.1 <br /> Installation will serve: R del� Commercial_ other__ <br /> Number of livuy unix: Number ofted rooms1 f. <br /> Character of soil to a t of 3 feet: �LtJe s 00 e" Water table da odzr !' "y <br /> SEPTIC TANK Type/M19 _T- Capacity �t�' No. Compartments 7— <br /> PKG. TREATMENT PLT. 0i 1 Method of Disposal �h N <br /> Distance to nearest. Well 4•^"/j� + Foundation� Property Line <br /> LEACHING LINE No. a �Length of lines w � Total knB[h/size 1 <br /> FILTER BED t.,1 Distance to nearest; Well 160 Foundation ;ZS '11`- Property Line <br /> SEEPAGE PITS I I Depth Sim Number <br /> SUMPS LI Distance to reemst: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1S <br /> I hereby cenity that I'have prepared this application and that the work will tot,done in accordance with San Joaquin county ordinances, state Laws, and <br /> rules and ngutationa of the San Joaquin county <br /> Home owner or Homed ageru'a signature cxrtifes the following: "I certify that in the performance of the work for which this permit is issued, I shelf not <br /> employ anyPer such rt+e Mor e3 to become subject to workmen's compensation laws of Californiaac <br /> California"Canfrta!e hiring or sub-contracting signature <br /> esrtdles the f inp ,.I COZZIy the pert hINIMe of the work for which this permit is issuednott <br /> , I shall employ paa subject to workman's eompenae. <br /> tion lawn o adaNa" <br /> The epplt must I or .H r wired ins coon om a drawing on ravens aide. <br /> Signed <br /> Till ^ .R.f1Dete; _ --2r/ <br /> FOR DEPARTMENT U5 ONLY <br /> Application Accepted by —""���-- 1'L_ Date Arae <br /> Pit or Grout Irepection by � ((��s(�'� � .-.��D.a/tte Final Inspection by u""'�Dato!/�/Z.�3 <br /> Additions) Cornmenw: CAC vv..JCaJLiLr. <br /> Applicant - Return all copies to: San Joaquin County P114,11C Health Services <br /> • Enm <br /> vironnental Health Perit/8ervices <br /> 445 N Sao Joaquin, P 0 Baa 2009, Stkn, CA 9520 <br /> AMOUNT DUE AMOUNT REMITTED 17 <br /> SASH RECEIVED 9Y DATE PERMa NO. <br /> IN <br /> EN t124( V,irate <br /> a.a ' � <br /> In— !2�y <br />