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2'NV1kt()1NkZNTAL HEAL'PH I!lljV?_:S,ION E. HAZFLTONr,AVE;.... PHONE ( )468-3420 1 (J f, ,� P 0 SOX 2008, STOCKTON C 5201 r C. Usk ng nq� {COmplete in Triplicate') Application is hereby mede.to San Joaquin County for a permSt to conetruct and/or Snata.11 the vork herein deacribed. This 6PPlIcation Se wade in cCMPlianea vith San Joaquin County Ordinance Ila. 549 andr1862 a Joaquin County Public Health Service#.11rr I nd the Rules abd Regulations at Ban i .lob Address �1 � � � -`S=1 t1�� j� �l rC �L r�- City — Lot Site/Acreme Y Owner's Nome C?• Y >> Address r i-tom 5"."_11 '! l i.f t?7-7 Phone Gt+ttlr3Clor Ytl��1Gr L,'Fd•(C1^r��;{Nc' AddrdSS (c:�, S �.2�-_ ,rr.��i"7 Ci; gyyy/ - c� S' 1? L,cen3e No CA - 2 ATL phont_4'iS TYPE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT-11:,r 1 DESTRUCTION GZ.Out of Service Well PUMP INSTALLATI N ❑ ❑ f r SYSTEM REPAIR ICI OTHER '] Monitoring well DISTANCE TO NEAREST. SEPTIC TANK 5 " f SEWER LINES S C_/f—I� OtSPQSAL FLD. PROP. LINE i FOUNDATION S-�� AGRICULTURE WELL �} OTHER WELL Z.' PITS/SUMPS 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION S'PECJFICATIONS E i Industrial / t ❑ Open f3attom ❑—Manteca Dia. of Well Excavation !i u Dia. of Well Geeing J (.I Domestic/Ptivale IYI Gravel Pack D Tracy Type of Casing Vc- Sc c� Specifications 1'1 Public t:1 Other f"l Oe11a 'I y Depth of Grout Seaf Type of Grout ltic'. � I i frrivatlon Approx. Depth f 1 Eastern Surf" Seal Instai .1 by Repair Work Dane L7 Typo of Pump i H.P. !i $18 a:f Work [lone �C A Lt ro K N+1} Weft Destruction Well Diameter r� Sealing Material i Depth; (ie jZ,,�.t Sir Depth _ - ?, S miller Material i Depth l�. 3 TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I 1;j(No septic system permittnd if pubfic sower is available within 200 feet) t� lneteflation will serve: Residence _ Comenarcial _ Other l v Number of living units: Number of bedrooms Character of 4011 to a depth of 3 feet: I� SEPTIC TANK ❑ Type/Mfg Water table depth h`M Capacity— PKG. TREATMENT PLT, [r No. Compartments Ij 13 if Method of picppaal Distance to nearest: Well Foundation I} ProFrerty Lina '� LEACHING LINE Cl No. b Length of linea li FILTER SED Total 3oi g size f 0 Distance to nearest: Well Foundation iPfoperty Line .4 I SEEPAGE PITS 11 Depth Sire I Numb,. SUMPS LI Distance to nearest: Well Foundation } DISPOSAL PONDS Q Property Line i I hereby certify that I have prepared this application and that the work will be done in sccor6nce with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County �Il 1 Home owner or licenced agent's signature oertifies the foffowing: '9 certify that in the perioranca of the work for which this permit is isaved, I shelf not employ any person in such rnanner as to-become subject to workman's compensation taws of!Calitorn[e." Contractor's hiring of subcontracting signature cartifies the following; "I certify that in the performance of the work for which this permit is issued, I shall em 10 tion laws of California." A y peropus subject to workman'9 compensa• } i The cpplicBnLlnust call for alt requiSred�in`spections yPomptatte drawing on reverse side, i Signed X :!r, ._f''_ .� R% [ /� !j F T 1 ---Title: *' —C r c i t'f :'L �� Date: FOR DEPARTMENT USE ONLY; Applicatlon Accepted by Il Dole res PH or.grout fntpsctSon by Data Final InspectioIn by Date Additional Comments: E r Y A licant - PP Return all copies to; baa Joaquin County Public Health Services, EnvironraentAl Health permit/Seriviees ''i G D 1601 E. ftaseltoa Ave.. P 0 Box 2009, Stockton, CA 95201 FE£ 1 INFO DUE AMOUNT ftEM[TTEb CK RECEIV350 BY CASH GATE PEAMIT'NO. ). totH 1 a R j4 7 1 rV.,r�y1 ' I 14•I5 ?ea ( i! r I d a� ST T �,• r i ;EO O