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APPLICATION S.AQUIN COUNTY Z,PUBLIC REALTHti/1sRVICES ENVIRONIMTAL--'-,TEAUH DIVISION 445 N SAN -,JOAQtiI11—i I? 'HOX& (209)468-3420 P O BOR--�-;9009 �;STOCK.Tok ` CA'- 95201 PERMIT EXPIRES 111,_ :AA'YROM DATE ISSUED (Completefrinn Tkiplieate) Application is hereby made to San Joaquin County for a pecan t ter cotisti�uet and/or install the Vork herein described. This application is made in compliance with San To*AIUji_Ccunty.1brdinancrt?.No. 31+9•.and 1862 and the Rules find Regulations of San Joaquin County Public Eealth Services. Job Address ' C+tY 'Lot Site/Acreage - a ,{ Owner's Name . rh 2M L, �e �. ,6i Y Y --- Address Pd a4hI.W .-.tie,. i �- ;. •- ;, e Contractor Address s'e N0, o2ArS�73 fFthone TYPE Of WELL/PUMP: ^-NEW.WELL '.e= I� I!Lfr 1EPLAC15ME Y 0 "DESTRUCTION C1 Out of Service Well ; ❑ *"4; :L q i ; ; ; monitoring Well- O PUMP INSTALLATION d '� � �„31fStEIMff�tAIF ;Of - Of HEW O T DISTANCE TO NEAREST: SEPTIC LANK t �'1t 5E�NEf1 I�1 k �, I J ¢� bI POSAL$ L0,. r PROP. LINE i. FOUNDATION " AGRiCtiLTUfE`�ArElt " , G = bl'F�EFt WELL: ..... INTENDED USETYPE OF WELL PROBLEM/tRNA} CN$TiiU �fON SPECIPICATtONS n Industrial ❑ Open Bottorri ~ ❑.Manteca•, " t�f31sR of Well Excavatrottk" Dla of.Well Casing �Q Domestic/Private Gravel Pack �,'1~iacy'`} _ �yprof Citllnp 'pU� :SpacillCationf :-• F11Public 1-1 Other C7 Delta j lIpth of Gidut Saes's� f �- TyP.of:Gt a;Z2J I I Irrigation —Approx. Depth i I:kastem p' Surface�S•dl+(hitslled hY Repair Work Done 0 Type of Pump State,Work Done Sea Well Destruction ❑ Well Diameter, '> ling,Material'-&-Dep fir. ... th t Depth !'filar 11at axial. Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i 1, DESTRUCTIO?tI4ANo septic: system permitted if public sewer is available within 200 fest-l' :N Installation will serve: Residence_;Commercial '_'. {r athar Number of living units: Number of bedroll-1 r TE'` x r "" ,� ..•.�. -. _F Y.. ` Character of Boll to a depth of 3 feet: ` r Water table depth SEPTIC TANK. ❑ Type/Mfg city No. Compartmo/ is F PKG. TREATMENT PLT.❑ . s. �g r * Method of Disposal Distance to nearest Well .- FoundattOn Property Line, ? LEACHING LINE ❑ - No. A Length of lines „Total length/elle FILTER BED ❑ Distance to nearest Well 3 �ndatibn �htoxperty Lina x � SEEPAGE,PITS 11 Depth 5iri ..,t"` NLfttbe� SUMPS LI Distance to nearest Wel;; Pourtdatbh -'� l4 i..lstt;party Line %- DISPOSAL PONDS ❑ ,_ nc -. s ,..a y.c �t• I hereby certify that l have prepared this application accordrinae.with.San JoaquiA bOunty didinilikos,state lows; an rules and regulations of the San Joaquin Count? ••' • "• " '" Home owner or licensed agent's signature certifies the follbwinl� -r'1 certify;thit-li!i.the perfornr1*AcA of the work tot Whkh this 04thih is issued. 1 shall not employ any person In such manner as to become subject to workman'a e i rmpensati6ri laws of CillfornlN."Contraetor'fi hirlhO bf t+ub•coritrecting signature certifies the following:"I certify that in the performance of the 4vork.fat whichthis¢sTmit It csausd,I shall imploV periona itibiact to workman's componsa-r- tion laws of California." - ��:A The applfcan ust call for ail requir nsj>.ctiom Cantpleee drawchd err rd-fide Signed itltff^�x Data. A11'PNI t USE21.1 OftlLlt l `4; Application Accepted by ,Mata "'`Alii Pit or Grout Inspection by 0111114s Pinarjhap/1 cit by Oate ?.g f2S Additional Comments: 16 emn - Applicant - Return all copies to:. Sao.Joaquin"Cotifttq Pub11a:,Health•Services Envirbnmental Heiilth°Pertiit/Servteali 445 R San`Jbiquitir, P ti. Bax 2009,:Stkn, DA 95201 AMOVNT DUE AMOUNT REMITfEb''' '. tt x RECEIVED 8Y DATE PERMIT NO. INFO CASH wNF °� EH 13.14IREV.fi�so EH i4da 2