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— APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �1 P 0 BOX 2009, STOCSTON, CA 95201 S PC I PERMIT ESPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t ty for a permit to construct and/or install the work herein described. This .to tO San San Joaquin Counwith Ban Joaquin County Ordinance No. 549 and and the Rules and Rei lationa o application is made in adef San pppllcntion is hereby made i Joaquin County Public Health services. dl� Gl ep Lot Size/Acreage _ K A-Gr, — 1 �D 8'(o ICJ s 13 City —`� 1Job Address C �?� 0 7 Phone �� , �'f' t�9t1tZ� Address !� YI.Owner's Name — ;. License No. PLhone Address onlractor WELL REPLACEMENT ❑ DESTRUCTION L� Out of Service.Wg�l Gl. TYf E OF WELL/PUMP: iNEW WELL ❑ OTHER ❑ monitoring Well C1 ER LINE SEW PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ i r. DISPOSAL FLO. PROP. LINE SJ�----- i DISTANCE TO NEAREST: SEPTIC TANK ��--- ---OTHER WELL P17S1SUMP5 � _ - •- ' FOUNDATION .AGRICULTURE-WELLA TYPE OF,WELL - L PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of INe6rCasireg ❑ INTENDED USE �JWall Excavation n Bottom— ` Manteca' a t=i Indusv;al ❑ open / Specifications L7 Tracy Type of Casing_!=__-.�_.-�_- CCl] Domestic/ Gravel Pack Depth of GrouPs t Seal TYof Grout _ ['1 Publics I1 Other ' r..- n Delta Approx.:0epfh i I Eastern Surface Seal Alnstalled'%by Y �- ` W I I lrri{t8iion , H.P. State Work-Done --- Repair Work Dane 0 Typeof Pump Sealing Material & Depth 3. Well Destruction O Weft Diameter Biller Material d��Depth " ! Depth - TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIRIAODITIONrI'I' DTRUCTION aNailabe within 200 feet.) it public sewer is , Initailafibn will serve:: Resrdence� Commercial Other--- Number of living units" Number of bedrooms Water table depth Character of soil to a depth of 3 feet:` r No, Compartments D Type/Mfg .__ Capacity— . >.- y� E SEPTIC TANK _ _ _ T' i. •1 e-Meth6d"dhJ4posal f I PKG'TREATMENT PLT.�1" .'Proper Lined `` ` Distance to nearest: Well foundation p y 4 r Total lengthisize LEACHING LINE ❑ No. >frl Length of lines Property Line =- FILTER BED ❑ Distance to nearest: Well Foundation_�� ---------- FILTER z � Sl I DeptF Sire SEEPAGE PITS Number Foundation.��— Property Line SUMPS LI Distance to nearest: Well DISPOSAL PONDS ❑ I harsh certify that I have prepared This application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and'C rulas and regulations of the San Joaquin county signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not fe Home owner or licensed agent's employ any certifies the person in such 1 certify teat in the perfto ormance of to work lion which this permit s issued,f I shall employ persons 1subj ct to workman's ompensa• following, „ r- tion laws of California." I The applicant t c II for all required ins ctions. omplata drawing on reverse side. o Date: 1-�7�- qZ f /yigned Title: N1, P - - DEPARTMENT USE ONLY _. Date_WL_-� Area ` Application Accepted by Date — Final Inspection by Data Pit or Grout Inspection by r f Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services j Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2049, Stkn, GA 95201 t CK RECEIVED BY DATE PERMIT N0, FEE AMOUNT-DUE AMOUNT REMITTED CASH INFO r� T / J /__ I r�Z QI�! ., 0 ., ::A� EH 13.24 t/1 EV.I/H 51 ` r !- EH 14-26