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`SNA , SACRRMEhdTO TEL :916.,,-§52--66h�S Oct 05292- 10 :52 1-40 ,007 ADPL I CATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r5y P O BOX 2009, STOCKTON,- CA 9520 �� ` 2MIT =TRES 1, YEAR.F T "T 9222 (Complete in Triplicate) r�,'`i , >i tppiicatioa Is.hereby made to tinll Lees Joaquin County for a permit to construct and/or instathen YorJc'tt�rclir d aCr3'bed:' application is de in compli.ace vith San Joaquin County[Ordinance Ho. 549 and 1862 and the Rules Lad Re:gulatiana of Se,n Joaquin CaesatY PUblIC Xe*Alto F$erv16az. 3 Z O z C✓i !T"�mi•►�l.C.tr M Job Address CityS V CK M f4 Gat Size/Acreage , ilo400 i aoorH e_E'14t1e3+t eA.lKwrt-Y S0IrZr310 Owner's No ZIP/e I L C 0c" row AQdreEf j'vlew r LLA w `t Brnit$9 Phone za P�«ice //09 ' hrdl� Cesysrp/ GTi �� a _T_/-a �6Q►l"�!� 's Contractor Addrtsi L.icenae NO.7 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT M OESTRUCTION Gl Out of service well 1 'F PUMP INSTALLATION ❑ SYSTEM Monitoring we11 �l'� EM REPAIR ❑ OTHER 0 t ,I DISTANCE TO NEAREST: SEPTIC TANK 'A SEWER LINES ?52 f:24c- DISPOSAL FLO.All,#� PROP. LINE S FOUNDATION ,..�._ AGRICULTURE WELL '&& OTHER WELL__4&_ 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - tt 17 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Ois. of Wali Casio DI OomesllC/Private ❑ vel Pack ❑Tracy Type of Casino �VL Specification t: 1'1 Public I. Oth*f 11 Delta Depth of Grout Seal ��_ _ Type of Grout4M_EX7 XSW t1`E I I Irrigation Approx. Oapth I I Eastern Surface Set11 Ins10846 by Repair Work Gane 0 Type of Punas -__ H.P. State Work pane Well Destruction ❑ Well Diameter Sailing Haterlal ill Depth a7/r ✓Afwrv'!dk^ Otpth Filler Material i Depth O-26' I TYPE OF SEPTfC WORK: NEW INSTALLATION 1 t REPAIR/ADDITION I I DESTRUCTION 111No septic %Vitem permitted if public sew*,4s available within 2W feet.! installation will setae: Residence Commercial" Other Number of Being units; Number of bedrooms Character of $oft to a depth of 3 t6et: Water table depth I t SEPTIC TANK ❑ Two/Mfg CapacitY.�_..,. N0. Gompertrr+enu PKG. TREATMENT PLT.Qb Method at Oitposel _. ,,. _- owance to nearest: Well __ _ Fqundetion Property Lina A LEACHING LINE Gl No. b Length of lines ,. Total Iongth/site `FILTER BED ❑ Distance to nearest: Well Foundation Property Line , SEEPAGE PITS I I Depth Sizer _ Number } 'mSUMPS Ll Distance to nearest: Weft .__.__- Foundation Property Line DISPOSAL PONOS C3 I hereby certify that I have prepared this application and that the work will be done in accordance with San Josovin County ordinances, state taws, ane rules and regulations of the San Joaquin County Home owner or licensed agent's slpnalvre certifies the foliowino: "1 certify that in the performance of the work for which this permit is issued, I shall Oct employ any parson In such manner at;to become subiaci to workman's compensation laws of Calitomia." Contractor's.hiring or suG•Cgntracfing signatur! ,cenlfies the 1*11O ving; "I certify that in the performance of the work for which this parmit is issued.I*hall employ persons subject to workman's Compensa- lion laws of California," 'The applicant m r 11 requir pections. Complete dfawinp an reverse side, • ' ..Signed ,rata "At Oate: /� '••"� !' RTMENT USE ONLY Application Accepted by -17 pate A=�/9Area Pit or Grout Inspection by _ Data Final Inspection-by Date ' Additional Comments: Applicant - Return all copies to: Sea Joaquin County Public' tiealtb $erviceaq Enviroamental Health Permit/services p2 le � 446 N Sac. Joaquin, F O Box 2000, Stkn. CA 9820L i_5 r FEE AMOvNr Ott@ OUNT f1EMITTEO C>< RECEIVED aY fNFO CASH RATE PERrVtIT'NQ, I ISN frEV.TI�a, .G�v