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I Post-lt'`brant!fax transmittal memo 7671 '-pages o, 'LIC 1'i'l ON co. co m 'Y PUBLIC HEALTH11�ICES/fes, , 5� 'S-JC �inJ: 'AL HEALTH DIVISION a . Dept. Phone is, 1,110NE (.3209);46$ z 42(x'_. !_ Z 4(-5,03 3 STOCKTON ''� Fax# r CA.•95201 1 YEAR FROM DATE I AUM (CUinplete in Triplicate') .+4' Application is hereby made,to San Joaquin County for a permit to construct and/or nate a application is made in COW11ance with Ban Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of Sana Joaquin County Public Health Services. Job Address t/O W Ciry��"� `�� Lot Size/Acreage 2Q_ L*lf � Owner's Name _ r/�L! r oma'Address � Csf�_ I'lpo_�QaW Phone Q '9 ��•.. a Contractor fL7lG'/wrGlZfCAdd ress oo J fl o� License No.c, Z-_'Y9b�yaPhone TYPE OF WELL/PUMP: Z - NEW WELLS54 WELL REPLACEMENT Il '` DESTRUCTION C.i out or service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR fr �ySPt OTHER Q Monitoring wall _0 DISTANCE TO NEAREST: SEPTiC TANK _ SEWER LINES 6 r aft/rel,,DIOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _&.!±_I?0THEAr.WELLZ2!-- PITS/SUMPS fNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X Indust6allVavri/&e4#5 ❑ Open Bottom C7 Manteca Dia. of well Excavation Dia. of Wall Casing , L! Dot nestiC/Private $1 Gravel Pack 1 Tracy Type of Casing_ `{SVG'` Spacilicationse u' ' �t8_ I'I Public 1-1 Other fl Delia Depth of Grout Seal: O fee,t Type of Grout 20 4 E I InrOation [5-Aplwom. Depth I I Eastarn '' 5urtace Saul Instilled by Repan Work Oona L) Type of Pump H P. Slats'Work Done�. Well Destruction ❑ Well Diameter Sealing Material & Depth: 1 Depth Filler Material A Depth I TYPE OF SEPTIC WORK: NEW INSTALL.ATfON i I REPAIR/ADDITION I I DESTRUCTION I IiiINo se tics stem P Y permitted if public sewer is available within 200 leet.l i Installation will ser": Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water able depth SEPTIC TANK 0 Type/Mfg Capacity E - No. C i PKG. TREATMENT PLT. ❑ orn"rtmants " Method of Disposal Distance to nearest: Well Foundation Property Line _ LEACHING LINE Cl No. 6 Length of lines Total Iength/sire FILTER BED l 1 Distance to nearest: well Foundation Property Line ai SEEPAGE PITS' If Depth Sirs. � Numbei 1 SUMPS LI Distance to nearest: Well Foundation - F DISPOSAL PONDS ❑ Property Lina +' II I hereby amity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and ragufattone of the San Joaquin County Home owner or licensed agent's signature unifies the following: "I certify that in the performOnce of i;the work for which this permitrs issued, t shall not employ any person in such manner as to become subject to workman's compensation taws o1 California.'• Contractors hiring or sub-contracting signature certifies the following:•'f certify that in the performance of the work for which this permit is issued, I ahhll employ persons subject to workman's compensa- tion laws of Californls." { The applicant must call lot ell required intpeciions. Complete drawing on reverse side. il� I Signed X r� Title: _:� I �` Date: FOR DEPARTMENT USE ONLY Application Accaptad by ,� r d � D Date "U' Area Pit or Grout In !� I ttpaation by Date _ Final Inspection by Oats e,n 3; Additions! Comments: 4 Appttcant - .Neturn all copies to: $sn Joaquin County Pugllc Health Services Bovironmental Itealth Permit/Services 445 N San .foayerin, P 0 llnx 2008, Stkn, CA 95201 FEE AMOUNT DtlE AMOUNT REMITTED CK AECHVED By g rNfO CASA DATE PEAMIT'NO, fH it as }