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S1SID0103D 7 8t133NIDN3 �' <br /> Z-� viN'. r Hnvo 'N01X30JLS '�NI'df10t9J <br /> on. wo NOLLVI00` ��,,dnn3 D'�0f9R PERM11I M <br /> ZO ILL I t-Z6 SMOc7A�t�t7"�'12 ff rMLIC HEALTH S1M✓I CES <br /> roN l�erodd ENV I RONLIENTAL HEALTH DIVISION <br /> 11 Lj <br /> ' 0£ OZ OL 0 <br /> PERU I T ESP I RES 1 YEAR FROM D E B 0 2 1QA3 <br /> _ <br /> (Complete n Triplica w r��{ <br /> ® +� P S at1.//tltllN Cr :^,I <br /> gplication is hereby ride to San Joaquin County for a pQIAAI)N to construct and/o tea eji $felt¢;Setif.. s <br /> pplication is =M licence vith San Joaquin County Ordinance No.,;%t eMffdb h� �1 X11 xAVM SON <br /> Joaquin Count }ypS t3 Services. �u++�� �I L — <br /> ob Address r K U, !)AVP DP_j yE_ nTjrmv4F <br /> c,,I I e Bti u0IN ® r <br /> wnl11l's Name `-ter Gc.�4 LA/ � ��7��z /t$SQC. Address ��SW /V Y /J V �— P e���� W 3 <br /> I I I I �— .3 L Phone <br /> ant ctor 46s -Nl'rF}� �deieks �N1VClln CDtA�i}4 �A <br /> YP WELL/f1mg,4 NEW WELL 3) WELL REPLACEMENT n DESTRUCTION of Service Well O <br /> PUMP INSTALLATIIO/ U-8 SYST REPAIR ❑ OTHER Monitoring Well CJ <br /> IS NCE TO SEPTIC TANK N�A SEWER LINEE�4—��— DISPOSA FLD. P 0 LINE <br /> GRIC�I LTU WELL u/!f OTHER W LL PI /SUMPS <br /> I ENDED USE WELL �FtOgWMARECONSTRUCTION SPECIFIC IS D II <br /> In atrial Sp�Qpon Bptem Manteca Dia. of Well Excavation Dia. f ell Casing <br /> [ID -tic/Privet y Fek L7 Tracy I Type of Casing_ p SpecIi ations' <br /> I I Pt�� Pt r Delta Depth of Grout Seal Typo o Grouter <br /> I I Irrll Iation pyrex. Depth 1 I Eastern I udSurfaca Soal Installed by <br /> po r Work Do _H*_j UItDN State Work Done_ <br /> oil ostructio�nr, ❑ Well Diameter I 1 0 Sealing R':n6terial E Depth f/Vl,1-p►r t <br /> Isa 'A Depth 51 g-8 Filler Mterial 6 Depth o <br /> y <br /> TYPq PF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I A11�-ti4lrsBptrl?sp ted if public sewer is <br /> r — — — auailablo�ithir�2011 f A <br /> Ins Ration I servo: Residence_ ommerciai_ Other <br /> Nu bor of • ng units: Number rooms `� F <br /> T MIN <br /> C ter of d to o doth of 3 foot: — Water table do t <br /> P TANK ❑ Typo/Mfg a ty No. Gompartis <br /> P G. REATM NT PLT. ❑ I I Method of Di sal <br /> I Distance to rloareot W 11� �Fqundat nProperty Lino < <br /> I G <br /> L ACING LINI Cl No. & Length of linos — Total length/size <br /> F1 LT BED NP%%tanco tc noarest: I Well 1 Fbunda ori ft80 tI 1B� <br /> 20UEU8flllElgj r — _ <br /> SEP E PITS I I Depth Size es d <br /> L — -Nuntu iOul I) <br /> Sim L I Distance tc noerostZ Well Fourdatiod Property Lino <br /> D SP AL PO S ❑ ONJIO — - <br /> 1 or certify at 1 have prepared this pplic tion a id that the work will be one in accordance with San Joaquin coun y ordinances, state laws, and <br /> r a fpd rogufa ions of the San Joaquin C <br /> H wner or 'tensed agent's tignatur ff os thefollowing: "I certify that in 1hajerf <br /> _ pormance of the work for which t is permit is issued, I shall not <br /> o p any peram in such manner as to ofno tubAct to workman's compo atlonrlawo of California." Contractor's hirir I or subcontracting signature <br /> e if�' }the foto •ng: "I certify that int Wormenc s*rrr►it is issued, I shall employ poraons su joct to workmen's componsa- <br /> f n U of CaEi ornb." - <br /> T o applictvat-tLwit cCII for VI required Inspections. Complete drawing on reverse . <br /> Signed 6 � S Title: &21Date: /?� 1 <br /> - FOR DEPARTMENT USE ONLY 12AI <br /> Application Accepted by Data Area <br /> Pit or Grout Inepoction by Date Final Inspection by Date �Z <br /> Additional Commonto; (.til. <br /> Applicant - Return all copies to: San Joaquin County Public He th Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INF <br /> O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY n/DATE ypP�jERMIT'NO. <br /> . EM 14-24 IREV.tiasi 1 �� I rv�J 4VJ /✓1 - 41 OI <br /> EH 1�•2� <br />