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X: meo APPLICATION r'`• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTjiL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468 3420 P 0 BOX 2009, STOC%TON, CA 25201 } PERMIT EXPIRES 1 YEAR FROM 2ATE ISSUED "• (Complete is Triplicate) Application is hereby made.to Sen Joaquin county for a permit to construct and/or Install the vork hezeln described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Dan Joaquin County Nblic Health Services. /S!G Z S. �7-'/f_AZ G!/L ICA Cit �S r_ Lot Site reale Job Address y—�6S '� i Owner's Name D, T CAVA) Address Phone _ Conuactor f=l_o'/I7 ?f-_. WelCrp Address_Z��t264dE[4x- _Licensa No.-�V;Lr-If G Pt,one s- .�,.' j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTr1UCT10N L)Out of.Aervics Well PUMP INSTALLATION C SYSTEM REPAIR Ll OTHER f7 MoalWritl�Well QQ DISTANCE TO NEAREST: SEr rIC TANK SEWER LINES ._ DISPOSAL FLS. PROP. LINE ( +, FOUNDATION AGRICULJ'URE WELL OTHER WELL P1T$/3UMPT_ INTENDED USE TYPE OF WELL PROBLEM A, EA CONSTPUCTION SPECIFICATIONS t ❑Industrial G Open Bottom ❑Manteca Ois.of Well Escevabon — Ola.of Wall Ceaing C.l Domestic/Private ❑Gravol Pack ❑ Tracy Type of Cesinp__,.___ _ Spectficalione. g i'I Public (7 OtM+ (-1 Delia Depth of Grout Seat Type of 0 j I I Irtipstio —n Approx. Depth I I Eastern Su0sce Sael Insrell-id by ! i �^ Repair Work Done U Type of Pump H,P, Stasi'Mork Dana Well Des'auction ❑ Wel(Diameter Sealins Material a Lepth yp Depth Tiller Material i Depth 4 TYPE Os SEPTIC WORK: NEW INSTALLATION I I REPAIR IADOITION DESTRUCTION I I (No septic system tied H pt Nowa is available witz leaf.) Installation viii serve: Residence✓Commercial_ Other— /nGf3/GE �, f� -03 } Number of living unite if Number of teirooms Character of soil to a depth of S'set: _'CeVAIG vV .4+s1 -Wets tab4o 64)th SEPTIC TANK O Type/Mfpi "---K IST.&6-Capacity f Z-a o Pio. Compartnwtb _ 1 PKG.TREATMENT PLT. Method of qt�lbesl to nearest: Well 3iAd><- Foundation1L'_ Property Lina /&Sf[ t . r Total len e r�8� , C LEACHING LINE No.8 Length of lines -i!�i'�� ' 'c -o g1h/s@ f FILTER BED M Distance to nearest: Well 30c5Ff Foundation �;W Property Line Z&V Y SEEPAGE PITS 'I Depth �2 Sin ;L)if f Number ,4 SUMPS �Q Distance to nearest: Well ZLJ" Foundation Property Line :11` _ r DISPOSAL PONDS ❑ { 1 herby certify that I haw 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 San Jcaquin County Home owner or licsnsad agent's signature wrtiftes the following:"I•certify that In the nerformance of the work for which this permit b issued,I dish not employ any person M such manner as to becomd subject to workmsn's compsnsa>ton Laws of California."Contracto4s hiring or sub-controciing signature `- certifies Ge following:"I certify that Li the performance of the work for which this permit is issued,I shad employ persons subject to workmen's comport". tan Izwo of California." '+ The applicant must call for da regvired inspections.Complete drawing on reverse side. i Sig, /�L�n-sr Ttb: Data. =7--9 Z- OR D RTM T USE ONLY ' Application Accepted by _ — Dats Ana nfi ph or Grout Inspection by Date Final Inapecllon b Dot } Additional Comments: --- t Applicant - Return all copies to: Ran Joaquin County Public Health Services Dnvironnental Health Permit/Services 445 N San Jotquln, Box 2000, 9tkn, CA 95201 FEE AMOUNT DUF. AMOUNT REMITTED K RECEIVED eY DATE •ERMIT'NO "+��pq+��, INFC, "5 tH INEV,"liI fHIPA N•1♦ � r ::7R�ncA:.aeHu:9A4a'>2gW51'R'�i:6AiitSAS 'rfii1.4t.'B:EFcrsU9Mw^N1ticfr.,i,q��Y t..WjEB