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i cofy ,1!>I'I.1CA�'i ON i''i7!l 3'fittidl'f' I SAN JOAQIJIN COUNTY PUDLIC HEALTH .11JXfICR3 I ?� ENVIRONUZNI`AL HEAi.'PII DIVISION P C BOX 2009, STOCKTON, CA 95201 (209) 468-3447 r (Complote in Triplicate) 11ppllcatlon is hereby aside to San ;o q,,tc Cosnty'for a permit to construct anelor install the work hcreln described. Thin application Is Md. In empliance with San Joagi,ln-County Ord.ner.cc ND. 549 cid 166C aro the-Auras and Regulations of Can J064ulo County Public Health Sarvicea. I{ Job Address ?S ' •,- /-ry �`r ../'(t Lot Sisc/Acreage/�LsCV, J k' Owner's Hama��L`lr.s:'i S -i�/,�!'/� A,Idross,��.-'7r�___-_T. �'yr t''r -i,T�-'Z C-f`'.L:'. I hang t::xl t I&•�J n Con is SC for / �1 ! Nl.tti�_Ames 4(]Ci.C r!)!-�� TYPE OF WELLIPUMP NEW WELL ❑ WELL REPLACEMENT DESTR,;CT1014>ZOut of Service well 0 - - PUMP INSTALLATION R SYSTEM REPAIR ❑ OTHER 0 Mvnitorl:ng Well ET DISTANCE TO NEAREST: SEPTIC TANK —"0:' f'� SEWER LINES•'?_`s'r L_ DISPOSAL FLOA �.,, PROP- LINE _1L� FOUNDATION AGRICULTURE'NELL _ -'_ GTHER WELL '" _ PITSISUMPS - _ INTENDED USE TYPE OF WELL PRO{31I.47 AAE A CONSTRrJCTIO_`l S^ECIFt(;ATIONS li Ir fl-Indwinal U OMn Bonom �Manleca Urs. sf Welt E.cavalron W�_ _It Dia. of WellGesir{) DornestsclPnvate - f Gravel Pack t7 Tracy Type of _rr__,:13Ln Spvcifievions,� 0 Public C7 Othr, 0 Oaka Dapth of G,o, Kcal Type of GrnulZ)r;'l' U l(nyahon Ai!rlST_ xo,pros. Depth _-D Eastern Surface Sail inslatled b; „ I' Repair Work Done Ll Type of Pwnp ii P.___._ State'Work Dona Well Destruction 0 Waff Diameter � Scaling Material i Depth Ihpth !'. S-` Filler !Eaten,: L t)epth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 R5PAt141AOUITiON M DESTRUCTION CI :No sepire ivstem permitted it public.wwar is t available within 230 laol] Insi0stion will serve: Raeidance_ Commercial _ _ Other - Fj Number of Fvrng units: Number of beorooms Character of sod to a deptts of 7 Eeet: __- ,__Water lablo depth SEPTIC TANK 0 TypelMtg _ Capacity— No, Comparlmiints PKG.TREATMENT PLT.a Msihoi of Disposal /r V Distance io nearest: Well_ Founciadon Fropany Line LEACHING LINE L1 No. 6 Length of lines _ To!ai lengthfaire__ -J FILTER BED CI Distance to nearest: Well Foundation_ Property Lino SEEPAGE PITS 11 E+eptti Sas �. Number I' ` SUMPS LI D.stanca tD r.Arest: Weil Founoatrori Properly Line DISPOSAL PONDS 0 _ _ 117 t hereby cenify that 1 have prepared this applrcaDon and iral the work ndl La Cone in,actor Cance with San Joaquin county Ord�nancaa. stave laws.and rules and regulations of the San Joaawn Ccur.ay Nome owner or beenkad agent's signature crrt,l,es Ina todowrng "i Candy That in the piston*ince o!ins work lot which this permit is it sled,f shalt not employ any parson in rlych manner as io b•7cvrne V.:ulact:o workman's comoartiv,on laws of CaUForrna."Conuacici's hinny or sub-contfarung signature unifies the following:'f certify p+at in the performenca al the worn,for whrCn this p ermri.a issued.f shaii emp of perAQnz subject to workman's cumpanaa- tion Laws of Californla." The appiicant must call for all required i speclrons. Comp'n'.e drawing on reverse irda- A r ! I �, i 5;9 .�. .✓, _—v— Title: ��i_s^��_ a._ — Date: 4� a FOR DEPARTMENT USE ONLY l Application Accsptad by yN., - \ �. - � _ Daia_ }` Pit of Trout nspectar; (Gale Fine!Ins`peniobyDate Lit >� / t Addiilonal Com,nanta: AF-11;Cant - ttetuira all copies to: Sari JOAQUIN COUNTY PLI13LIC NEALTff 1EAVICKS ENVIAtlNNE3iTAL HEALTH DIVISION PERBES/SERVICl• {Js^ r I ��E _"� r 445 N 5P4 JOAQUIN, P D DOX 200p, 2TUCKT0II, CA 14:.201 FEE � LK a r Nfo AMOUNT pup i wasltln;T nCksr'7ED rAS� RECOWL)E'l DAT. Pt rcM l7 Nq. �� : -- { 5 COPY