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r�L�ol�► v� ��..,Jw_ ' lUI COUNTY PUBLIC HEALTH SSS o So. &Vis D SCall 0 0 V RON1sENTA4*hEALTH D I V I S O SAN JOAQUIT4, PHONE (209) gg13 PERMIT EXPIRES 1 YEAR FROM DAT O BOX 2009, STOC%TON, CA ( /�/^� Solo?gN� GD5�4 VbQJ Q (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and/o V t! application Se cgde Sn commllnnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ,Ct Joaquin County blit Healtb Serovice.. ,,� Job Address ^T=v�f�/j�ly� - '"-t Stze/jAAcreage Owner's Name Address PL�L/`� 1 s Phone le Conlracior Address se No. Phone TYPE OF WELL/PUMP. NE WELL WELL REPLACEMENT DESTRUCTION L) Out of Service Well ❑ PUMP INSTALLA ION 15-� . SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well CT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .. DISPOSAL FCO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE -- TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS H ❑ Industrial - pen swlont ❑ Manteca Dia. of Well Excavation Cia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications �•t 1 PuIll - 4 1 Omer Ll Delta Depth o1 Grout Seal Type of Grout— Apple.. siTiripatipn _ Apple.. D I Eaftem Surface Saul installed y Repair Work Done ❑ Type of Pump f / u.P. Islatpork Done Well Destiuction ❑ Well Diameter Sealing Material i Depth ( _ Depth L Flller Material a Depth VNVI, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No satinn system permitted if public sewer is available within 200 feet.) Installation will servo: Residence_- Commercial _ Other Number of awing units: _ Number of bedrooms ^Y T tel\ Character o1 soil to a depth of 3 feet f's�.VCGat�r/t�Fah�Ia�depm SEPTIC TANK ❑ Type/Mfg Capacity REGI RdndllM1ments \111 PKG..TREATMENT PLT. ❑ _ -,_ _ JAR l?leLIoa�Disposal V Distance to nearest: •Well Foundation gAN�JF14BeA�r IIv S v OF t �9ES LEACHING LINE C1No. b Length of lines WWWOTH DIViS FILTER BED ' r❑ Distance to nearest: Well Foundation ENV Property Line SEEPAGE PITS I I Depth Size ,Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat. laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which tnia permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion Iti of California." The applicant m cat for 1 re ed in pectlons, Complete drawing on Signed Date: ��/ / FOR DEPARTMENT USE ONLY Arerm Application tion Acceptetl yDate a a ' s _ 1'1' 9 Final Ina b �7 Pit r Grout napoction d4al ate pec ion by Oate Additional Comments: 3104- SROf?A6o'l3-' xN aoy9 Applicant - Return ypi.9 San Joaquin County Public Health Services q gD5'O 1-s 333057 �Dnvlronmen tel Health Perml t/Services t13 p(]�' SGSJ ,(J j/ �{�W 0073 495'N can Joaquin, P O Box 2009, S[kn, CA 95201 ^n INSE FO AMOUNT DUE AMOUNT R ITTED =-C CK EDgy, DAT /C! ClV a�.1eL EM 112IHIM s Is 270