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h fV ADPLICti rrnu --. , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES •-�+ r ,5 I '�NL` � ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE (209)468-3420 P O BOX 2009, STOCITON, CA 95201 E!ERM1m KM1RES 1 YEAR FROM DATE ISSUER (Complete in Triplicate) Applicn>:ion is hereby made to Ban Joaquin County fora permit to construct and/or install the voric herela described. This application is made in ecaviianee with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Jauquin County Public Health Services. 1()17 1J_ ynspynit-B Axre C+tv Manteca Lot Size/Acreage , 11,7012 sa ft .Jab Address owners Name Yen HAferAddress _p n Rnx 7917. Mante (Phone 3563 Omec Circle Contrat!or B&F Drilling Address (cense No .519428 Phone - TYPE OF WELUPUMP NEW WELL WELL REPLACEMENT n DESTRUCTION Ell or Service well C3 PUMP INSTALLATION 0 SYSTEM REPAIR CJ OTHER O Monitaring Well 11 � DISTANCE TO NEAREST SEPTIC TANK SEWER LINES ._ DISPOSAL FLO._ PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELLw-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rt _ Dia of Wall Casing C1 Industrial ❑ Open Bottom W Manteca Die of Weil Excavation PVC Specifications Sch. 40 -Sch. Cl Domestic/Prrvate 124*rsvel Peck ❑ Tracy Type of Casing r ,`event I t prrblie fl Other 1"I Delta Depth of Grout Seal $ Type of Grou I I Irniatton 2.S2Approx Depth I 1 Eastern Surface Seal Installed by Reosrr work Oona L3 Type of Pump— H P State ork Done .. al - $' Wail Destruction ❑ Well Ooameter _ Sealing Material l Depth Depth 2S i tiller Material i Depttf S� ca sand filter, ac_ 10 TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCT I I allo septiablewr hit system rented it putilK sewer is 'AftInstalletron Will serve Rasidenc Commercial — Other humber of living units Hu r of bedrooms Water table depth rsctar of soil to a depth of 3 lest. Cepacrty. No Compartments SEPTIC TANK 0 Type/Mfg Method of Disposal PKG TREATMENT PLT ❑ Distance to neentst' Foundation Property Line LEACHING LINE ❑ No 8 Length of lin Total length/size FILTER BED ❑ Distance to nears Well undstion Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest We11 �_� Foundation Property Line- DISPOSAL PONOS ❑ ~ I hereby comfy that 1 have 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 Joaquin County Home ownar or licensed agent's signature Certifies the following 'I certify that In the performance of the work for which this permit is tssuad I shall not employ any Person in such^tis^^°tut°become subject to workman's corripensatlon laws of California,,Contractors hiring of sub-contracting signature certlites the following "!certify that In the performance of the work for which this permit is Issued,!shall employ persons subject to vrorkntan's cismpensa tion jaws of California" If The applicant naval coq fo all required laspection■ Complete drawing on reverse side Signed X Title 6 _ Date- Sig FOR DEPARTMENT USE ONLY �- �,_ .A I 11 � Ara Application Accepted by v pita Date _ _ Date Pit or Grout lnapectrpn byFinal Inspection by. I I f I 6,A ionai Comments Applicant - Return all copies to San Joaquin County Public Health Services I i /�•�II ti Environmental Health Permit/Services M k lJ 445 N San Joaquin, P 0 Box 2009, Stka, CA 93201 1 CXS FEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO INFO B I I III o �ij � �� I I � ill M�h'T'`O T'•II�� P I I I I iL��E1,I� r��i I �� I �� Y�I'� �� I �� I� dli�� I�� ' till