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4 ' APPLICATION YOR PERMIT ED A r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES V ENVIRON11ENTAL HEALTH DIVISION $ 1601 E. HAZELTON AVE. , PHONE (209)466-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIU13 1 YEAR FROM BATE ISSUED Com lete in Tri y licate P Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. Thin - .'- application Is made In comylianee vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations-of,Ban �r r � -r Joaquin County Public Health Services. - - p-' r 'Y sr .S , Job Address' 3 5Q 1-_�.1j..r }Gln�t\'1�; Ciry S]r'+-��r Lot Sixty/Acreage r/ C? _ _ .U1-a=1 Owner's Name C + Address S��_�_ ��n 11.E C'_ ___ Phone Contrclor fUS - Address - f_ License No. Phon TYPE OF WELLlPUMP: Y NEW WELL �31 WELL REPLACEMENT ❑ DESTRUCTION"Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring 5te11`,`�" i pleTnf•.C,:5'J NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE ry FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM ARE CONSTRUCTION SPECIFICATIONS y , i r L7 industrial: ❑Open Bottom ❑ anteca Dia.of Well Excavation 0 _� . Die.of Well Casing {. V Domestic lPrivate >,3 Gravel Pack ❑Tracy Type of Cea a f-'PUL Fty4s�- Spetifleations {< I'1 Public is Other TSef Depth of Grout Seat �'an Type of Grout , �'ApMox. Depth t I Eastern Surface Seal Installed by t 41 51t , i ne U Type o[Pump H,P. Stale Work Done WorkDoSealing Mattial fDepth rf a, Well Destruction. ❑ Well Diameter f Depth Piller Material is Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIRrADOITION I I DESTRUCTIL_1!I I INo septic syslanr petmitled if public sewer is4.�R 4 A. available within 200 test.) ;r r �: all Insralletiontwiilserve:- Residence—.,._- Commercial__ Other Number of living units: Number of Weooms " S- - ,_ I. b +� 4,,1 r �" '_,Character or soil to a'dapth of 3 fee:. f -Water tabes depth _. SEPTIC TANK,,-',--- pe . ❑ . TylMfg Capacity No.Cornpartmenta. r f l PK:? TREATMiNT PLT.0 ,x-Mathod 6(Disposal `4 Distance to nearest Well_ Foundation Property Line ' �:• 1 '. LEACHING LINE ❑ No.f4 Length of lines Toter length/sirs k FILTER BED n „Distance to nearest: Well Foundation Proparry Lina Sts �ytiXb 1 SEEPAGE PITS JI. Depth Sire Number f ' { sSUMPS c I LI 'Distance to noerest: Well foundation Property Lina a i k tR nb q f�7s'vr , DISPOSAL PONDS 0 _. _ „, � _ r r _ `p I hereby certify that I have prepared this application and that the work will be done in accvrdan„e with San, oa Joaquin county ordinances,state laws;