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k)PPLJCA T I ON FOR PERN T a r• m ` �'`ti d '��. �ter•- .SM JOAQUIN JOAQUIN COMI PUBLIC aEALT11 SERVIOU .BNVIRONVENT" H;AALTH DIVISION P 0 BOX 20090 NTOCKTON, CA 9..52071 (209) 466-3447 JAN 2 5 1391 IMYT FXPREP I YEAR Mm Al I�IRQP�;1MFN-f/aL H�r�'%1:�1 i (Complete in Triplicate) PERMIT/SERVIM Appitceeton to hereby made to Ban Joaquin County Por a pormit,to conotruct and/or hetero. tho vork heroin deegribed. Thio opplloatlon ie =de in eco4litwoo eith San Joaquin County Ordinance Ito, 549 and 1862 e.nd the Rulea and Repuletione of San Joaquin County Publio 11taltiriperpoea. r _ t uI,o sae/ cCemo Job Addraad �� f . � Owner's Nam } Addrt35s Phone 6 / - 2( C n, � Y� � dress 'Icense No. f?. Phone 'TYPE F WELL/PUl,4P: NEV> C7 WELL REPLACEM NT [� DESTRUCTION [1 Out or Service all C1 PUMP INSTALLATIQ� SYSTEM REPAIR q OTHER 0 Monitoring Well C) `DISTANCE TO NEAREST: SEPTIC YANk'I S1 WER LINES. �y DISPOSAL FLD:_ PROP. LINE . FOUNOAYION AGRICULruR'E WELL "OTHER WELL"_'_ PITS/SUMPS INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industriat� 0 Open Bottom 0 Manteca Die. of Well Excavaslon _ Dia. of Well Catling onflQolfo/Prlvala •Ll Gravel Pack 0 Tracy Typo of Casing, _ Specificeriona Vj Public f1 Other 0 pelta Depth of Grout Sol Type of Grout 0 Irriperian Approx. Depth Eworn Surface Setif Inylallud b'y_ IT Repair Work Clone 0 Type of Pumg t N.PSlate Work 0 I Wali Doilrucllon 0 Well Diameter Saalirta kfat.erlai b Depth _ ..Depth Biller IdatertaA fr Depth YPE OF SEPTIC WORK: NEW INSTALLATION Q 'FtEPAIWADOITION Cf DESTRUCTION GI INo septic fyitem pormilted it pi bfic sower is available within 200 feel.) - Intlollation wilt*ervo: Raildence_ Comm areiel�_ Other Number of living unito: Number of bedroomp ' Charaotar of soil to a depth of 3 feel: ��.., .-, - - ---- Water table depth - }L, SEPP(C TANK Q Type/Mfg 1 f Capacity No. Cornpat1manta I PKG. TREATMENT ALT;C1 - !/ ' Method of Olaposel d Dfsience to nosrasl: -Well Poundadon Property Line-, LEACHINO LINE C11 No>&r'La6gth of lines, Twel length/al:e FILTES BED �` CI Dialance to noamou Wait m Foundeuon Property Lina SEEPAQE PITS).+.1 I I 66`}Iwl�__ Sire Number �. SUMPS - l I E Qfstance to naeroel: '` Well �. Foundation Property Line »DISPOSAL PONOS .I LL7�•at� �' -.{ _ _ I horoby certify that I heve(propared thio applicallon and that the work will be done in accordance with San Joaquin county urdinancas. state laws, end rules; end reeulalions of IgOageh'ian J6�4uln County r Noma owner or Ilcenaod 'e sibn3rure cerlifies the fbilo ving. "I canify that In the performance of the work for which this permit Is issued, 1 0e0 nor f ernploy any portion In such manner es io"become t<ubjec` to workmen's compensation lawa of California," Contreclor's hiring or sub-conlracling flonelure r cerilfles the following "I carifly that In Ih9 par&Mance f the work for vm�?ch thieparmh I la®ued�I ehal„ i omyi p,-�re�Qe subiect to workman's compensa k Ilan laws W Ca)ifornla,"'^-- "�''I --"�"-`"'__" The oppllcan al G (or 11'requlrad,Ins�Gtiona. Corr plots drawing on r foe slda: I "tit 5ipnad c� �k�' i L�? TIUe: — Date: `c�1 l 15014 DEPARTMENT USE ONL Appllclllon Accepted by Dale Area �u Pit or Growl Inepoolon by 10010 Final Inspdction 6 Dale Addlilona!Com"ntal ----- --- --, - - ---'- ---`} -. ,_ .� _ Applicant - Return -U coptea tot SAN JOAQUIN COUNT -P.013 I'HEALTff L30YICEB kNV1Yi0NkiFNTAL NEALT�I UYYI8I0N PrRkIT/BP.RVICES 446 N 8AN JOAQUIN, P•O BOX 3000, UrMXTON, CA 08241 L FEE I INFO AMOVIvT DUE- AMOUNT REMITTED SN RECEIVED BY DATE PERMIT"N0.