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DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation 8 a Type of Casing cch .40 Pile, Depth of Grout Seal 9 -I2 Surface Seal Installed by State Work Done Sealing Material & Depth Rellinzirite tl I- nner Material & Depth 0.3 /*slily 4,?1 4;7 -34- TYPE OF WELL PROBLEM AREA Open Bottom 0 Manteca Gravel Pack 0 Tracy NI Other MuliTti2114- Delta Approx. Depth I I Eastern Type of Pump H.P. Well Diameter Depth INTENDED USE C) Industrial 1.1 Domestic/Private El Public i I Irrigation Repair Work Done 0 Well Destruction 0 Dia. of Well Casing Specifications 0M 2:1 b look Type of Groutfrlf71-4/ii-e, or,- and cented.A- Area 3 its .sikoo03'2._ • APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISS (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in comiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Job Address ()CACI EtinbarcAde ro Dri.ve City Lot Lot Size/Acreage VA /94o 5att P inque/ Or. IP eo Owners Name eqetctu Group Address tdabilifeif e e / cc1'cory4 Phone ' , PO tick ,A23 i (qi 6) Contractor At/Vika Vulikli_C2r.,A. Address fiaocho C..ordziva-LA "I S74( License No. (-..)-726, i 7 Phone es:2.-4i cS-F N . TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT r) DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION C SYSTEM REPAIR CI OTHER 0 Monitoring Well x CV FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Joaquin County Public Health Services. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 203 feet.) Installation will serve: Residence Commercial Other Number of living units. Number of bedrooms Character of soil to a depth of 3 feet . Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal LEACHING LINE FILTER BED No. & Length of lines Distance to nearest: Distance to nearest: Well Well Foundation Foundation Total length/size Property Line Property Line li SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side.w . Title: Serliok^ Cecdoli DEPARTMENT USE ONLY Date Final Inspection by Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 Application Accepted by Pit or Grout Inspection by Additional Comments: Signed X - 11L.ty, R. . Date Date: .--414- EV 13-24-1APIP. ma Si EH 14.2e 4 FEE INFO 14t,l) AMOUNT DUE AMOUNT REMITTED CCX-Oe CASH RECEIVED BY DATE PERMIT NO. 5s 1 • X C1.161) I/7y 5-61A4-vi S-N -g4- jzze).