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SAN' .JOAQUIN COUNTY PUBLIC HEALTH SERVICES 15-Fo0T bf:67p ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 r� t3otzr�CAPR 0 9 1992 P O BOX 2009, STQCgTON, CA 95201 HAIA- bold, w6m5' r 5I-NVIRONMENTAL HEALTH EICPEC. � ry t EiJC�Uc�✓!' E YEAR F8 DATE SU PERM 1T/§ y1t1 (Complete in Triplicate) Application is hereby made to Sao Joa quia County for a permit to eornntruct end/or lnstaLl the work herein described. This application Is ohile in coagtliance With San Joaquin County Ordinance No, 51+9 and 1862 and the Rules and Regulations of Ban Joaquin County public Health Servicer. Job Address 3aa �a�TH hflF�iu/& 9 City/'gym Lot Stae/Acreage !✓1G�L. ��►� � � x _J-17767-3 Phony�a/ I33��Z ZTR14=r�Owner's Nome Address /S ' Z 5 r=2e--S /�ST�f�f G5 �2 7 q 0ZLS-7o2 I � s Address ill? �4• `y ]�/ License No. J ! Phone _ r Conirattor�N TYPE OF WELL/PUMP' �(/ NEW�WELL r0 W�LI. REPLACEMENT C) DESTRUCTION L'� Out of Seryied well C1 P MP INSTALLATI0 G SYSTEM REPAIR L') OT C] Monitoring Well DISTANCE TO N_EAAEST. SEPTIC TANK f SEWER ONES O6 . DISPOSAL FLf PROP. LINE �Da FOUNDATION 1 1 - AGRICULTURE WELL OTHER WELL PITSISUMPS y` s 'INT El' 6 U8E"Tl ` TYPE OF-WE L PROBLEMAREA' `CONSTRUCTION SPECIFtCATIDNS�— n Industrial ; O O orni © Mantecs Dia of Welt Excavation Dia. of Well Caging F.t DomestiClPrivate C1 G Wei Peck L1 Tracy Type of Casing___,_ 5peciticadons I'1 Public 1;} cher I-1 Delta Depth of Grout Seal r5 Type of Grout S CC C �J f I Irrigation prox. D E n Surface Sawl Insterlud by Repair Worst Dbne U Type of u State Work Done �— Well Destruction C Well Diameter 6a Meterlal dr Depth 1,11v4- Depth / /� Depth 1 ller al 5 Dopth ✓" Irl r, TYPE OF SEPTIC WORK. NEW INSTALLATION i I R IAOD 1 i TRUCTION I I (No septic system permitted if public sttwof is '�✓ I available within 200 laet.l lnstollation wIII serve: Residence Commercial Other Number of living units; _,..� Number of bedrooms Charactei of#oil to 0 depth of 3 toot: T --- --- _ — Water table depth SEPTIC TANK. O -Type/Mfg I Capacity No, Compartments PKG. 'TREATMENT PLT. o � Method of Disposal Distance to n4er$tc Well Foundation _ Property Line i LEACHING LINE 0 No. & Langiti of fines Total lengthisize Y t FILTER BED n Distance to newest: Well „ Foundation -- -- . Property Line SEEPAGE PITS i ) 1 Depth Site - _ ___ Number SUMPS L) Distance to nearest: Wall _ Foundation Property Line DISPOSAL PONDS O I hereby certify that I h;ve prepared this application and that the work will be done in accordance With San JOequln County OrdinaneeS, state laws. end L-roaHoene owner or I+cen"tl!agent'a slgnature certifies the following: certify that in the performance of the work fol which this permit is iso_- Hoene s anis mgut6wns of the .Son JoAQw;n_C0-.u%ty'y ;._ '^„'r —""'""'^"""""a'�°"R'-'�'"""�` i shalt net l4 employ any person in a6ch m6rinae as to become subject to workmen's compensation laws of California," Coottector's hiringor sub•conrractin signature certifies tho following: "i certify that in the performance of the work for which this permit is issued,I shati employ persons subject to workman's compents- tion laws of California.' The appiieent moat Cel pitaired i spection mplete Drawing on reverse Si e. ` Signed Tiao: Data: FUR D PARTMENT USE ONLY Application Accepted byt - _ Date Area Pit or Grout Inspection bA _ - Data _ Final IInspaction b Date - rr I Additional ComrntoMa; t/ 11x' G1 Applicant - Return all copiers to: Sort Joaquin County Public Health BervlceR Environmental health Permit/Services 445 N San Joaquin, P U Box 2009, 6thn, CA 95201 L/ FEE I IAMOUNT OVE AMOUNT REMITTED K RECEIVEO By OATS PERhtI'I NO. INFO CASH i t�•28 U I i t