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APF .KATION FOR PERMIT SAN JOtQUI:: C:.iUNTY PUBLIC HEALTH SERVICES EIVTRON-x124TAL HEALTH DIVISION 4/35• N'SAN JCAQU,!N, PHONE (209)468-3420 P O'I50R 2009, STOCBTON, CA 95201 PERIfIT F�=Rn^S 1 YEAR FROM nArF r�ertr n .(Complete in Triplicate) Application is harcty made•to San .:�•.Qu in Calrrtty for a permit tc constn-ct and/or install the vork herein described. This aFplicAtion is made in cotpllance with P4an JoaQuin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sen Joaquln County A.bIle Health Services. Job Addsa`�Gr� ��✓ ,. r) �Z/) n :r7 .2CC Y�'o !L' /�.vrrft.� � Address Lot Size/Acreage _7j Ace..J _ XOwne('sNams �] �(Y/G- ndme�s _ ��-1�.._CL�_ �/ ..l_IG e ,1/•c G9 s)�E,L Phone J �( /O q :d )(Contractor--L) �vs Addrest _ License No. Phone _ TYPE OF WELL/PUMP NEW WELL ❑_ WELL REP!ACEMENt !1DESTRUCTION ❑Out of &envies Well O n PUfdP INSTAL!ATION C SYSTEM REPAIRX� OTHER O Monitoring Well C I S !S DISTANCE rO NEAREST: SEPTIC TANK SEWIR LINES DISPOSAL FLD. PROP. LINE _ t FOIJNDArION AGkICULTUFE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROB!EM•AREA CONSTRUCTION SPECIFICATIONS '( Ci Industrial O Open Bottom U Manteca Dia.of Wall EacevAiior Ms.of Well Casing C.i Domestic/Private CI Gravel Pmck In Tracy Tyx of Casing_._ Specificarkns I'1 Public C1 Otter fl Delta Depth GI Grout Seal Type of Grout _ Irriustion _Apptox. Depth 11 Etsurn surface Saul Installed by -- RaOeir LVctk Ooru ,)I� Type of Purt:p H.P. State Work Done 7 t WR Deetruvion O Well Diametsi Sealing Material A Depth Depth Filler I(Aterial Li Depth C TYPE CF SsPTIC WORK: NEW INSrA1LAT10N I I REPAIF/ADDITION I I DESTRUCTION I I INo saptie system pgrmtasd if pet+ls7 sewer is available within 200 feet.) InstaupKon wilt serve: Residence_ Cortmmer.ial Ot..,%, N,unttrer o1 kving units:_ Number of bedtot:ms Churton of rood to a depth rf 3 feet:_ -Water table depth _ 1 SEPTIC TANK ❑ Type/?Jfg Capacity No.Comparments a PKG.TREATMENT PLT.❑ Method of nispossi ? Distance to noarest: We7I Foundation Property Line 6 LEACHING LINE CI No.!Length of lines _—� Total length/sirs }ILTEC BED 0 Distance co rw,a,est: M'IAl Foundation Property Line _ FEEPAGE PITS 11 Depth ---silo__, Number SUMPS LI Gistsnci to newest: Well _ Foundation - Property Line D!SfOSAL PONDS O _ _ r I hereby cortity that I have prepared this application enC,that trio wt'it will be done in accordance with San Joam ir.county ordinances,state lows,and rubs and r-gulatrona of the Sar Actaquin ecunty Homs owner cr licensed Vent's signature certit.ss the follcWwtnV.•"I certify that in the MAormanw of the work for which this permit is issued,1 shall not employ any parson in such manned as to become sliNect to Workman's compensation laws of California-Contractor's hiring or sue contracting signature certifies the following:"I certify that in the p11410fM& G of the'M•ork for which this permit is issued,I atoll employ persons subject to workfmn's carpensr tion!awe of Callforr"." The epplir�at' st case for Ap r. kW Met satlom.Complete drswmg o�nww/reraids. / X Stpnad ` cr t( t�� _—. TitleData: /L f c---;POkE.PARTMENT USE ON!_Y r, Af,pikatlon Accaprsd by �- �� f Z At". Ph or Orcut Inspection by Date_ _,_ Frai Inspection by Additional Comments: _<.e ,/'6yt• ,l• r "'Ler ��_•i� Applicant - Return all copies to: San Joaqudo-County Public Health Services •r7 ��•Y' -cam Environments] H �� Health Permit/Servieea 7,,r 445 it an Jonqutn, P 0 Box 2000, Stkn, CA 95201 � d FEE AM•WNT DtIE AMOVNT RGMtt�EB K R!CEIVED eY DATE PERMIT'NO. INFO CASH Ito 1s-X IRN. raat l� rt I t_' tet tr.as � .✓ � 'S!?ir�. Irl � 3_}mom 11 oil law.