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. _�n.�„Rr•ra Ly may,[ ��..�� .�.Y�i.1 °\ y Sop( TOAQDIN COUNTY PUBLIC HEALTH SERVICES NMENTAL HEALTH DIVISIO ENVIRON 4w PHONE (209)468-3420 • 445 ,a SAN 2009,NkOCKTON, CA 95201 P a��BO% 2009, vv7m"e'X TRES 1 YEAR FR0M DATE- ISSIU . (Complete In Tri-Mcate) lations of San Application Se hereby made,to San work Joequin count;-for a permit to construct and/or inetell the Rules herein described. This epplicatian is made in compliance with San Joaquii,`ounty,Ordinance No. 5+9 and 1862 ar# the Rules and Regi Joaquin County Public Health Services• /J !�� Lot Size/Acreage ! Gity Job Address �kzk Rhona er t P� .4.., Ownei s Name Address A \ ( -,QPhand `^ C ��. Liu License No. 1�-C��.J?f1' _Address,! pE$7RUCTt0N `l Out of Service�Uell ❑ -Contractor. —� NEW WELL ❑ WELL REPLA MENT CI Monitoring Well ❑ TYPE OF WELL/PUMP SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE _— SEWER LINES —' OTHER WELL PITS/SUMPS FOUNDATION .— DISTANCE TO NEAREST: SEPTIC YANK AGRICULTURE WELL -----'�--- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAI ICN_ Dia of Well Casing INTENDED USE - � Die, of Well Excavatmn ❑ open Bottom G Manteca C) Industr specifications Tracy Type of Casing__--- _1` O Gravel Pack - Type of Grout ❑ Domestic/Private n Delta Depth of Grout .I I'1 Public 1-1OtherSurface Seal Installed by I 1 Irrigation _App"I Depth I I Eastern State Work Done-eJ H.P. 7 of Pump Sealing lfaterial i Depth \ Repair Work Done ❑ YOa \ Well Destruction ❑ Well D'�a+necer ?I ler Material i,Depth Depth -- available within 200 fist.) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I lNo'septic system gmiaeo if public aawer�i�, .- /Other installation will serve: Resldenu— Commercial_ � Z' � Number of living units: Number of bedrooms r ., _ Water table depth . -Character of soil to a depth of 3 feet: OePacttY C. .� No. Compartments �fI SEPTIC TANK (:jType/Mfg f Method o1 Disposal / + PKG. TREATMENT PLT. 13 it "C- ,.r! Foundation Property line -..� '- - Distance to neilirest: Well FG--- Total length/size \ r LEACHING LINE ❑F No'8 Length of lines >> _c^'yq/.•Propbr4i Li752 o near . iWHI�Q� Foundation—.�s-- FILTER BED r L) Distance'test 1 , / r aSixa � �/_,N�utm/ber _ SEEPAGE PITS '. I I Depth I ar y) Foundation_.L-0 PrWorry Line - I SUMPS , LI,,•Distance to nearest: j Well�.+}+2— }�,� _�._,. . . - DISPOSAL PONDS - ❑ I. ,f 1 MrebY certify that I have Prepared this application and that the work'willoe Cone in accordance with San Joaquin county ortlinances, state to".-and rules and ragulatiore of the San Joaquin County Home owner or licensed agent's signature cettifietthe follow mgn artcompensaiwn jaw,ofCalifornia." Contractonce of%he work for/s hiring mo�sub-contracrmit is t�9 signature 1 employ any person ih such manner-sin he performance _ Homecandies the following:"1 certdy that in the peHotmance of the work for which this permit is issued,I shall employ persons subject to workmads clompensa- tion lows of California." Q 1 + . The applicant II for ell rt 'nspec[i s. Complete drawing on reverse ➢�� L- Dots: Titles -/'�� { SigneC - 6 } FOR DEPARTMENT USE ONLY Area I � Date I Application Accepted by a 6Mlate Dots qr9 2 i Final Inspection by T &V Grout Inspection by { 1r i Additional Comments: picant - Rturn all copies to: - Public Health 45201ApSnvironmentalHealth Perml (gervic es 09 tkn. CA *� n_P 0-9px_20 r � 445.N-Sao-Joaqu ' ..x. i a CK c RECEIVEDBY ` DATE PERMIT NO. i FEE AMOUNT DUE AMOUNT REMITTED^ CASH \ INFO . EH X24.,aEv.�..eitSR EN 14]0 r