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APPLICATION FOR PERU SAN JOAQUIN COUNTY PUBLIC REAL ENVIRONMENTAL HEALTH DIV 445 N SAN JOAQUIN, PHONE (20: P O BOX 2009, STOCSTON, C! (Complete in Triplica Application is hereby rude to Ban Joaquin County for a permit to construct and/or ioi applleatioe In trade in ceatpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules mad Regulations of Sam Joaquin County Public Health Services. Job Address 7, ' t City:1(t. , Lot Size/Acreage t �((cl. Owner's NMneC�4^r'11C.a,�.•� I u„ .L.:`. Address .� ,�Jr! Phone r Fi�CE-_- e,' 4 l� 1 Et�� `Z�` Phone �Lf Contract 3� �� Address +�.`,' J!o License No,- TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PAYMENT C) Industrial O Open Bottom 0 Manteca Dia. of Well Excavation _ r] Domestic/ Private O Gravel Pack 0 T:acy Type of Casing.. - �t 11 Public I:1 Other i-1 Delta Depth of Grout Seal 1993 I I Irrigation — Approx. Depth I I Eastern Surface Ssal Installed by SA Repair Work Done U T Pump Type H.P. 5tete Wark r U LIC HEALTH SERVICES Well Destrnnion d i We" Diameter Sealing Material i Depth IR014t�ti IAC�CT�SION Depth hiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION T REPAIR /ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is ImtaMation will tterw Residence Commercial J _available vrithin 200 leet.i u Other je yt fZt' >�t (1� /�'-�� 1� _ Number of Wing units: Number of ms �t`T"ti Character of soil to a depth of 3 feet: 4 +z "`— Water table depth SEPTIC TANK Type/Mfg ' I Z_'ZC Cap.,city �* No. Compartmsnta PKG. TREATMENT PLT. O / r Method of Ditt9osal Diawwo to nearest: Well -z4( ._ _ Foundation Property Line "'r' LEACHING UNE ';7tL1 No. i Length of knee - �� Tote[ length/site �� ` X, FILTER BED C_7 Distance to nearest: Well /['I" r i Foundation Property Una S 't SEEPAGE PITS Depth —Si. Number ~ SUMPS LI Dilunce to nowear Well Foundation /{ Property Line > DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regrrlmicim of the San Joaquin County Horns owner or kcensod agent's t+ig wwre certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ env person in such mariner as to become subject to workmen's compensation laws of California." Contractor's hiring ar sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I *hail employ per xim subject to workman's cornpenaa- tion It" of CalHorrtia-" The applicant must- I for all, ►eq� red inspections. Complete drawing on reverse side, Signed \ �.. _ { , �_._ •. < Title 1 Date: Application Accepted by ,"61or Grout Irarpection by Additional Comrrwnts. Applicant • iM1124 [RN. l psi Ea IA.30 FOR DEPARTMENT USE ONLY Date 2, 2 f CN Arse ate nal Inspection byr'�� 7 - Return all copies to: Sao Joaquin Coun P Public Health Services Environment ILI Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 952 (�C/ INFO j AMOUNT DUE AMREMITTED ED L-ASHCK MY DA N+ // % // 1 +/R/EECEEIVED �1�tj[ /9