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tt� ti! APPLICATION # _5 /n_3 SAN JOAOUIN COUNTY PUBLIC HEALTH SER ICS - EfJVIRONMENTAL IIEAI.TII nlVISION I i n # 445 N SAN JOAQUIN,PHONE(209)469-3420 / ti P O BOAC 383,STOCK'I-ON,CA 95201-03RR ' I�1r 14 1 PER MIT EXPIRES 1 YEAR FROM DATEEISSiIIP�tit, --�(Complete in Triplicate) Application is hereby nude to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San Jouquin County Development Title Section 9-1110.3 and Section 9.1115.3 and the Jules and Regulations of San Joaquin County Public Health Services. `r / r �L � g _ I W;C— JobAddress � ,ry -f0 Owner's Name L 4 S j �-� Ao/d,,esss ,✓�'�A e- Phone 4-r Contractor ��J u I(G r Ade,ess_--6 O�_Y:�—L cense No. �.5�� Phone 4-72- TYPE Of WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION O Out of Service Yell Cl PUMP INSTALLATION ❑ SYSTEM REPAIR E� OTHER ❑ Monitoring Well ❑ OISTA_NCE TO NEt,7EST: SEPTIC TANK SEWER LINES DISPOSAL F4D. PROP. LINE _ �(� FOUNDATION AGRICULTURE WELL __ OTHER WEL ''ITS/' MPS V-J INTENDED USE TvPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI n Industrial O Upon Bottom O Manteca Dia. of Well Excavation_- F� Well Casing O 171 Domeotc/Private ❑ Gnval Pack ❑ Tracy Type of Casing__ R -9 Rations I'I Public Cl Other I-) Delta Own,of Gout Soo L�/DUA,J �1,1J(S/Cd rf Grout I I Ifrrgatron Approx. Depth I I Eastern /Mato Soot Insulie VV 11__ �',.ttI{ ' Repair Work Done L) Typt of Pump H.P. State Work VICE ((, - Wall Destruction O Wol Diameter _ Boa-ling Material 4 Depth_ MA- Depth_ Tiller Matertal i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permstted it public newer it ^ available within 700 faat.l 1 ` Inalaustion willsena: Residence L Commercial— Other 1_ r Number of Fvrn4 units: Number of bedroorrs Character of seM to a depth of 3 feat: - rAn-c{n h ze Water table depth SEPTIC TANK, rd' Typsf�,lp _ _ L �L Cu'Jncr`'h�-Capauty Tr.A No. Compartments PKG. TREATMENT PLT.❑ f I Method of Ditpcaal Dir trice to nearest; Well IL-�,-._ Foundation-r�+— Property Line /'x601 J� LE ICHING LINE Pr No.g Length of lines -��..—�L2A To/al length/size FILTER BED n Distance to rarest Well Fovooshon_-- Property Line Ie)Ct SEEPAGE PITS V-C.op,h ?-S size.- SUMPS ias.-SUMPS LI Distance to mwerst � Wei, r ' _Q_ Fou.,wdetton _ Property Line_ip1L_ DISPOSAL PONDS_ O I hereby Certify that I haw proofed this apphcaucn and that the work will 9e done In accordance vain San Joaquin county ofd,nancaa,state lawn,and rules and rogulatlons of tho Sin Joaquin county - Hem.*owner or licensed 40oni't signature certifies the following: "I conify that in the performance of the work for which this permit is mettaerf,I"If not cmploY any person in such manner as to become subNcr to workman's compensation laws of CoMorell Contractor's hiring or subcontracting signature unities tin logovwng:"i certify that in the performance of the work for which this permit Is issued,I shall employ parsons subtoct to workman's compare. i tion lawn of Californif." The ataphc►.tt must CsN for all required intpec"nt. Complete drawing on reverie udo. 1 r 5 Sigisad X ►r' tU/-� Title: �11��1. r _— Dna: t f FOR DFPARTMENT USE ONLY i Application Accepted brlr _ Dots Area F r Or 'inspectiont^ .4L final inspection 3y Data J ddh 1 Comment., J Applicant - Return all copies to: San Joaquin County Public Health Scrv¢es y Environmental Health Permit/Services 445 N.San Joaquin.P.O.Eton R8,S,,kto A 95201.0383 FEE AMOUNT DUE AMOUNT IIEMITTED ASH �CEtIED ll DATE ►211MI7 H0. R INFO rr1� d L EN 1YN late.Iia al � /l/ rV V 1 '